
Book, 'l—'l 



CopghtN . 



COPYRIGHT DEPOSIT. 



n 



Tuberculosis 



OF 



The Nose and Throat 



BY 



LORENZO B. LOCKARD, M. D. 

I) 

LARYNGOLOGIST AND RHINOLOGIST TO THE JEWISH CONSUMPTIVES RELIEF 
SOCIETY SANATORIUM, THE Y. M. C. A. HEALTH FARM AND THE EVAN- 
GELICAL LUTHERAN SANATORIUM; FORMERLY LARYNGOLOGIST 
TO THE NATIONAL JEWISH HOSPITAL FOR CONSUMPTIVES 
AND MEMBER OF THE BOARD OF DIRECTORS OF THE 
AGNES MEMORIAL SANATORIUM ; ONE TIME 
PROFESSOR OF ANATOMY, TOLEDO MED- 
ICAL COLLEGE; FELLOW OF THE 
AMERICAN ACADEMY OF 
OPHTHAMOLOGY AND 
OTOLARYNGOL- 
OGY, ETC. 



WITH EIGHTY-FIVE ILLUSTRATIONS, SIXTY-FOUR OF THEM 

IN COLORS. 



C. V. MOSBY MEDICAL BOOK & PUBLISHING CO. 

St. Louis, 
1909 



\^ 



4. 



\ 



Copyrighted, 1909, 

by the 

C. V. Mosby Medical Book and Publishing Company. 



/ 



Cla.A, XT-Z^IS" 
AUG 18 1909 



Press of 

Stewart Scott Press Rooms. 
St. Louis, Mo. 






PREFACE 



The annual mortality from tuberculosis, in the 
United States, approximates 150,000, and from eight 
to ten times this number are affected, to some extent. 
with the disease. 

Statistics compiled from all parts of the world, in- 
cluding private as well as hospital and sanatoria 
records, show that complicating lesions of the throat 
occur in at least one-third of all persons with recog- 
nizable foci in the lungs. Autopsies upon individuals 
dead of consumption prove that nearly fifty per cent 
have tuberculous lesions in the larynx, but assuming 
only one of every four consumptives to be so affected, 
an ultra-conservative estimate, the fact is established 
that none other of the serious diseases to which the 
upper respiratory tract is subject approaches tuber- 
culosis in prevelancy nor in the unhappy consequences 
which it entails. : 

In every case the development of a focus in the 
larynx or pharynx increases . greatly the gravity of 
the constitutional malady, in many it produces pro- 
longed, and at times, almost intolerable pain and in a 
considerable proportion it proves the direct cause of 
death. Experience has demonstrated, however, that 
the larger number of such infections are preventable, 



that at least one-half of the already developed lesions 
can be brought to the stage of arrest, and that in the 
majority of those that do not so respond the more dis- 
tressing symptoms may be held in partial subjection. 

The chief reasons for the high mortality that has 
been witnessed are to be found, first, in the almost uni- 
versal neglect to make systematic examinations of the 
larynx in pulmonary patients until subjective symp- 
toms have developed, by which time the lesions have 
often passed the bounds of incipiency and the general 
vitality has become hopelessly impaired, and secondly, 
in the generally accepted but erroneous beliefs that 
laryngeal tuberculosis is almost invariably fatal and 
that treatment commonly does more harm than good. 

Early lesions subjected to treatment are usually 
curable, and the advanced not infrequently so, and 
when these facts are recognized the pessimism that 
rules to-day will be succeeded by a rational optimism 
with the natural results thereof; more persistent, 
prompt and intelligent, and therefore more effective 
management of all such cases. 

The main objects of this book are to place before the 
profession the modern views concerning the early re- 
cognition, the treatment and prognosis of the disease, 
in the hope that an increased faith in the efficacy of 
treatment and a full appreciation of the importance of 
earlv diagnosis and of routine examinations of the 
larynx in every consumptive, will be engendered. 

The author desires to make cordial acknowledgment 
of the writings of Gerber, Heymann and Wright, to 
which he is indebted for much of the historical and 
pathological material, and of all the classical works on 



Laryngology and Tuberculosis, from which he has at 
times freely translated and quoted. 

Of the drawings, Figures 2 and 3 are taken from the 
Seifert-Kahn Atlas, and Figure 4 from the well known 
work of Heinze. 

All the other illustrations are the work of Fred'k L. 
Cavalry, Jr., and, with a few exceptions, were made 
from specimens and patients under the direct super- 
vision of the author, who takes this opportunity of 
expressing his appreication of the skill and painstak- 
ing care given by the artist to every detail of the work. 

Denver, Colorado, November, 1908. 



- 



CONTENTS. 



CHAPTER I. 

Histokical Survey of Laryngeal Tuberculosis. 

Page 
Period antedating and including the recognition of the laryngeal 

tubercle, 400 B. C. to 1825 A. D— First attempts at the 
differentiation of phthisis and syphilis, 1829 to 1842. — Period 
of pathologic investigation, beginning in 1842. — Period of 
clinical observation, beginning in 1858. — Determination of 
the true nature of laryngeal tuberculosis, 1879. — Inaugura- 
tion of a rational therapy, 1886 13 

CHAPTER II. 

Etiology — Primary and Secondary Infections. 

Susceptibility of the larynx to infection. — Reputed instances of 
primary infection. — Recent discoveries invalidating pre- 
viously accepted conclusions. — Latent tuberculosis of the 
lymphatic system. — Frequency of primary glandular infec- 
tion. — Infection of the larynx by way of the tonsils and 
cervical glands. — Other cases of so-called primary laryngeal 
phthisis. — Cases illustrating the possibility of infection of 
the larynx by the glands. — Conditions favoring primary 
infection. — Practical application of the question 30 

CHAPTER III. 

Etiology — Endogenetic and Exogenetic Infection. 

Frequency of unilateral localization of the disease. — Primary 
unilateral paralysis. — Atrophy and fatty degeneration of 
the laryngeal muscles. — Constitutional predisposition of one 
side to infection. — Subepithelial distribution of the tuber- 
cles and bacilli. — Localization of the affected areas. — Arro- 
sion ulcers. — Auto-infection 47 



CHAPTER IV. 
Etiology — Predisposing Causes. 

Frequency of laryngeal tuberculosis. — Influence of age. — Sex. 
— Occupations. — Tobacco. — Alcohol. — Previous local dis- 
ease. — Acute laryngitis. — Chronic catarrhal laryngitis. — Na- 
tionality. — Physical characteristics. — Pregnancy 58 

CHAPTER V. 

Pathology. 

General phenomena due to the bacillus. — Local phenomena. 
— Characteristics of the infiltrate. — Tubercle. — Giant Cell. — 
Ulcer. — Distribution of the bacilli. — The tuberculoma. — The 
miliary tubercle. — The glands. — The blood-vessels. — The 
muscles. — The nerves. — The mucosa. — The cartilages. — 
Mixed infections 68 

CHAPTER VI. 

Subjective Symptoms. 

Symptoms peculiar to the lungs. — Symptoms peculiar to the 
larynx. — Symptoms common to the lungs and larynx. — 
Amblyphonia. — Aphonia. — Diplophonia. — Paralysis. — Pares- 
thesia. — Cough. — Secretions. — Fever. — Dysphagia. — Dyspnea 80 

CHAPTER VII. 

Objective Symptoms. 

Hyperemia. — Anemia. — The infiltrate. — The ulcer — The tumor. 
— The miliary tubercle. — Arrosion ulcers. — Perforations of 
the epiglottis. — Subglottic lesions. — Conditions secondary 
to ulceration and infiltration; Perichondritis. — Chondritis. 
— Anklylosis. — Edema. — Abscesses. — Adhesions 95 

CHAPTER VIII, 

Diagnosis. 

General features of the tuberculous infiltrate and ulcer. — Ane- 
mia. — Hyperemia. — Chronic catarrhal laryngitis. — New 
growths. — Pachydermia. — Syphilis. — Prolapse of the ven- 
tricle. — Lupus. — Leprosy. — Carcinoma 130 



CHAPTER IX. 
Prognosis. 

General pessimism regarding laryngeal tuberculosis. — Percent- 
age of present-day cures. — Influence of the pulmonary condi- 
tion. — The locale of the lesion in its prognostic significance. 
— The epiglottis. — Arytenoids. — Aryepiglottidean folds. — In- 
terarytenoid sulcus. — Vocal cords. — Ventricular bands. — 
Association of various lesions. — Infiltrative cases. — Ulcera- 
tive cases. — The voice. — Dysphagia. — Dyspnea. — Miliary 
tuberculosis. — Influence of pregnancy. — Spontaneous heal- 
ing. — Relapses 143 

CHAPTER X. 

Records. 

Showing possibilities of treatment in some apparently hopeless 

cases 163 

CHAPTER XI. 
Hygienic and Dietetic Treatment. 

General conditions influencing results of treatment. — Climate. 
— High altitudes. — Open-air treatment. — Sanatorium treat- 
ment. — Diet. — Methods of eating. — Enemata. — Influence of 
tobacco and alcohol. — Rest of the voice. — Nasal and pharyn- 
geal hygiene 175 

CHAPTER XII. 

Medicinal Treatment. 

Constitutional Treatment. — Sodium cinnamate. — Tuberculin. — 
Bacterial vaccines. — Control of cough. — Local treatment. 
Inhalations. — Sprays. — Insufflations. — Pigments. — Intra- 
tracheal injections. — Submucous injections. — The X-ray. — 
Radium. — The arc light. — 'Sunlight 195 

CHAPTER XIII. 

Surgical Treatment — Endolaryngeal Operations. 

Results to be anticipated from operative interference. — Type of 
cases to be operated. — Anesthesia. — Instruments. — Choice of 
Operation. — Incision. — Scarification. — Curettage. — Excision. 
■ — Galvano-cauterization. — Electrolysis. — Complications. — 
After-treatment 222 



CHAPTER XIV. 

Surgical Treatment — Extealaeyngeal Operations. 
Tracheotomy. — Intubation. — Thyrotomy.— Laryngectomy 246 

CHAPTER XV. 

The Nose. 

Historical survey. — Etiology. — Antitoxic properties of the nasal 
mucus. — Other protective agencies. — Primary infections. — 
Secondary infection. — Channels of infection. — Frequency of 
nasal tuberculosis. — Relation to lupus. — Influence of age 
and sex. — Ozena and tuberculosis. — Subjective symptoms. 
■ — Objective symptoms. — Regions affected. — Involvement of 
the accessory sinuses. — Diagnosis. — Prognosis. — Extension 
to the lacrimal duct. — The naso-pharynx. — Cervical glands. 
—Treatment £60 

CHAPTER XVI. 
The Naso-Pharynx. 

Historical survey. — Frequency of secondary involvement. — Fre- 
quency of primary disease of the tonsils. — Sources of infec- 
tion. — Anatomical peculiarities favoring infection. — Protec- 
tive agencies. — Role of the tonsils in the dissemination of 
tuberculosis. — Characteristics of adenoid tuberculosis. — The 
ulcer. — The tumor. — Diagnosis. — Prognosis. — Treatment.... 304 

CHAPTER XVII. 

The Pharynx. 

Historical survey. — Channels of infection. — Proportion of con- 
sumptives attacked. — Pharyngeal immunity. — Primary infec- 
tion. — Influence of age and sex.— Esophageal ulceration. — 
The faucial tonsils. — The tonsils as a point of entry for 
the bacilli. — Subjective symptoms. — Objective symptoms. — 
— Formation of cicatricial tissue. — Palatal perforations. — 
Retropharyngeal abscesses. — Diagnosis. — Prognosis. — Asso- 
ciated lesions. — Curative treatment. — Palliative treatment.. 327 



LARYNGEAL 
TUBERCULOSIS 



CHAPTER I. 
THE LARYNX. 

HISTORY. 

An historical survey of laryngeal tuberculosis can be 
most conveniently made by a division into epochs; 
epochs of achievement rather than the arbitrary one 
of years, or in other words, by considering the notable 
steps through which we have arrived at our present 
state of knowledge. These epochs are : — 

1. Period antedating and including the recognition 
of the laryngeal tubercle, 400 B. C. to 1825 A. D. 

2. First attempts at differentiation of phthisis and 
syphilis, 1829 to 1842. 

3. Period of pathologic investigation, beginning 
1842. 

4. Period of clinical observation, beginning 1858. 

5. Determination of the true nature of laryngeal 
phthisis, 1879. 

6 Inauguration of a rational therapy, 1886 
First Period: — The symptoms of consumption were 
clearly described by Hippocrates (460-377 B. C), 
and as he alluded to "ulcers in the tube of the lungs," 
it may justly be inferred that he had some conception 
of the disease as it appears in the larynx. 



14 LAKYXGEAL TUBERCULOSIS. 

From this time on no real advance, in so far as the 
larynx is concerned, was made nntil Matthew Baillie 
(The Works of Matthew Baillie, Vol. II, Page 84, 1825) 
described tubercles of the larynx and trachea with in- 
flammation and ulceration of the mucosa, associated 
with "scrofulous abscesses of the lungs." 

This description, in the posthumous edition of his 
"Works, 1825," shows his observations to have been 
made between this date and the year 1793, when in 
the "Morbid Anatomy of Some of the Most Important 
Parts of the Human Body," he referred to the frequent 
appearance of tubercles in the lungs, but denied their 
occurrence in the branches of the trachea, "where there 
are follicles." 

That tuber cules of the laryngeal mucosa were 
definitely recognized at this time is further evi- 
denced by a description of white miliary tubercles in 
the larynx of a man dead of pulmonary phthisis, by 
Broussais, in the Histoire des Phlegmasies, 1816. 

The pulmonary tubercle had been recognized and 
described during a period of almost two hundred years 
before Baillie and Broussais noted a corresponding 
condition of the larynx. 

Thus Sylvius (1614-1672) maintained the identity 
of the nodules found in the lungs and the disease known 
as phthisis, but erroneously considered the nodules to 
be enlarged lymph glands. Morton, 1689, showed that 
the turbercle was the necessary precursor of ulceration, 
and somewhat later, 1700, Magnetus described miliary 
tubercles. 

Fragmentary descriptions of various laryngeal 
lesions classified under the common name of phthisis, 



HISTORY. 15 

in which this disease and syphilis were hopelessly con- 
fused, were given by Morgagni (Be Sedibus et Causis 
Morborum, 1762) and Lientand )Histoire Anatomica 
Medico, , 1767). 

Morgagni recorded two cases that have been com- 
monly accepted as a definite recognition of phthisis, 
although there is no indisputable proof that they were 
not syphilitic. 

The one, quoted from Fantoni, concerned a man who 
for a long time before death suffered from severe 
dyspnea. Post-mortem examination showed a larynx 
so constricted by infiltration and ulceration of the ary- 
tenoid cartilages that only a small aperture remained. 

In 1704 Valsalva performed an autopsy upon an un- 
married woman of forty who had been a long time 
sufferer from symptoms presumably due to asthma. 

No cause for death being found, Valsalva, at Mor- 
gagni 's suggestion, opened the larynx from behind. It 
was extensively ulcerated and filled with a crum like 
grayish colored pus, fully accounting for the long con- 
tinued dyspnea. 

Lieutaud's cases are somewhat similar and it is im- 
possible to conjecture which of these two constitutional 
conditions, syphilis or phthisis, was responsible. 

Lieutaud's carefulness of research, however, is 
shown by his description, after numerous post-mor- 
tems, of the first two cases of laryngeal polypi. 

At this period phthisis was not alone confused with 
syphilis, but with all diseases accompanied by ulcera- 
tion, swelling, necrosis and abscess formation; i. e., 
carcinoma, perichondritis, etc. 

Petit (Biss. de phthisie laryngea, Montpelier, 1790) ; 



16 LAKYNGEAL TUBERCULOSIS. 

Sauvee (Rech. s. I. phthisie laryngee, Paris, 1802) ; 
Sigaud {Rech. s. I. phthisie laryngee, Strassb., 1819) ; 
and Portal (Obser. sur la Nature et sur le Traite- 
ment de la Phthisie pulmonaire, Paris, 1792), gave 
fairly comprehensive descriptions of the disease with- 
out, however, differentiating the tuberculous and 
syphilitic cases. 

By the end of the century the science of laryngology 
had only advanced to a stage permitting a division of 
laryngeal diseases into three groups; phthisis, croup 
and acute inflammations. 

Sachse {Beitr. z. genaueren Kenntnisz und Unter- 
scheidung der Kehlkopf-u. Luftrohenschivindsuchten, 
Hanover, 1821) and three years later Pravaz {Rech. 
et observ. p. serv. a Vhist. de la phthisie laryng. These 
de Paris), collected many cases and gave a complete 
resume of the literature preceding and including the 
era in which they wrote. 

The confusion of various diseases at this time, 
however, is shown by Pravaz 's statement that, "No 
one can doubt to-day that laryngeal phthisis may exist 
primarily." 

These "primary" cases were cured by the adminis- 
tration of mercury. 

Many theories were advanced as to the etiology of 
phthisical ulcerations of the larynx, and Columbat 
credited them to enlargment of the tonsils and uvula. 

Louis {Recherches Anatomica Pathologique sur la 
Phthisie, 1825) made the first real attempt at exact 
study and classification and although he failed to sub- 
stantiate Baillie and Broussais in regard to the occur- 
rence of laryngeal tubercles, he noted their fre- 



HISTORY. 17 

quent appearance in the lnngs. He credited laryngeal 
infection to the mechanical irritation of the mucosa 
by the poisonous pnlmonary excretions, and main- 
tained that those points most subject to insult by the 
passing secretions were most frequently affected, and 
that therefore the danger of infection decreased pro- 
portionately to the distance of the parts from the af- 
fected pulmonary areas. 

This last observation was undoubtedly based upon 
the records of his post-mortems on the "tracheal ar- 
tery" in 102 cases of pulmonary consumption, where 
he found tracheal involvement 31 times, laryngeal 22, 
and epiglottic 18 times. 

Louis's conception of etiology, while containing 
much of error, had a germ of truth and has been ac- 
cepted to a certain degree by many modern observers. 

The theory that some tuberculous ulcers are of a 
catarrhal nature, long maintained by him, and to 
which he reverts in the 1813 edition of his works, has 
been generally abandoned but the majority of present 
day investigators credit the occurrence of some lesions 
— the so-called arrosion, corrosion or diphtheritic 
ulcers — to the mechanical irritation produced by 
cough, cachexia and sputum, resulting in superficial 
necrosis and subsequent infection by the bacillus. 

The existence of catarrhal ulcers in the larynges of 
tuberculous individuals is strongly combatted by Jona- 
than Wright. 

Borsieri in 1826 said: "There are those who think 
ulcers of the larynx and the aspera arteria, because 
they are not situated in the lungs, should be excluded 
from phthisis. However, from these lesions also the 



18 LARYNGEAL TUBERCULOSIS. 

body often wastes away, and is consumed by a slow 
fever just as iii the parent disease.'' 

Second Period: — Albers (Die Pathol, it. Therap. der 
Kehlkopfkrankheiten, Leipzig, 1829), in a painstaking 
review of the literature of laryngeal phthisis, noted 
the occurrence of tubercles and gave a lucid descrip- 
tion of their clinical appearance and transformation 
into ulcers. 

To this author can be accredited the first serious at- 
tempt to differentiate tuberculosis and syphilis, and 
this may well be considered the second great step 
toward an intelligent understanding of the disease as 
localized in the larynx. 

A decade later, Barth (Memoir e sur les ulcerations 
des voies aeriennes, Archives Generates de Medicine, 
1839) succeeded in furthering the differential diagnosis 
of the two conditions. 

Three years before this communication by Barth, 
Trousseau and Belloc won the prize offered by the 
Paris Academy for the best difinition and description 
of laryngeal phthisis, in their essay entitled: "Traite 
Prat, de la Phthisie Laryngee Chronique, et des Mala- 
dies de la Voix, 1837." 

They denned the disease as "tout alteration du lar- 
ynx, pouvant amener la consomption ou la mort. en 
quelque maniere que ce soit. ,J 

They maintained the principle of occasional primary 
localization of the tuberculous process in the larynx, a 
much discussed question at the present time, but 
admitted its general dependence upon preceding pul- 
monary involvement. 



HISTOKY. 19 

They included in their category of laryngeal 
phthisis : 

"1. Simple laryngeal phthisis produced by the 
common causes of inflammation in general, without 
pulmonary phthisis. 

"2. Syphilitic laryngeal phthisis. 

"3. Cancerous laryngeal phthisis. 

"4. Tubercular laryngeal phthisis. 

"Notwithstanding their recognition of tubercle in 
their last division, we see in their first the influence of 
the catarrhal theory of Louis." Cit. from Jonathan 
"Wright (The Nose and Throat in Medical History). 

In this essay they outlined the first rational therapy 
for laryngeal diseases : — douches, swabbing and the 
auto-insufflation of powders through curved cannu- 
lae. 

Third Period: — With Eokitansky we note a still 
further advance in the differentiation of phthisis and 
syphilis, and what was of infinitely greater worth in 
its influence upon the advancement of laryngology, a 
beginning of comprehensive study of the morbid 
lesions of tuberculous and other laryngeal diseases. 
While many of the ideas advanced by him were later 
abandoned, others were based upon truths that obtain 
to a considerable degree in the pathology of to-day. 

In the "Lehrbuch d, Path. Anat., 1842- '46," he de- 
scribes the tubercle as an exudate of inspissated pro- 
teins, and states that tubercles and scrofulous glands 
are identical structures, and that ulcers result from 
the breaking down of the exudate. He likewise deals 
with the question of predisposition, the tuberculous 
habitus, and considers it of great importance. 



20 LAKYNGEAL TUBEECULOSIS. 

Tubercles of the air passages frequently occur — 
most often in the larynx, rarely in the trachea and 
larger bronchi, and again more frequently in the 
smaller tubes. 

In the larynx their favorite site is the posterior wall 
over the musculus transversus, an observation sub- 
stantiated to-day by clinical research. 

The theory that tuberculous ulcerations of the larynx 
are dependent upon mechanical injury through the 
anatomical relationship of the parts, and especially 
when these favored areas have been previously re- 
duced in resistance through injury or inflammation, 
was advanced by Eheiner (Ueb. d. Ulcerations proc. im 
Larynx, Virch. Arch., v., 1853) and fourteen years 
later by Colberg (Beitr. z. norm. u. path. Anat. d. 
Lunge, Arch. f. Klin. Med., II, 1867). 

The basis • of this theory was the assumption that 
ulcerations generally occur upon symmetrical points, 
points which normally come in contact during the phy- 
siologic movements of the larynx, i. e., the vocal pro- 
cesses in speaking and the free edge of the epiglottis 
and the tips of the arytenoids in swallowing. In refu- 
tation of this it is only necessary to suggest that initial 
]esions are rarely seen upon these "favored" points; 
on the epiglottis the usual location is the laryngeal 
surface, the tip usually becoming affected at a later 
period through extension, while the vocal processes are 
not involved to a much greater extent than the other 
segments of the cords. 

Neither the epiglottis nor the arytenoids exhibit 
the same percentage of involvement as other points 
not subject to rubbing or pressure, i. e., the vocal cords 



HISTORY. 21 

and inter-arytenoid sulcus, and the ventricular bands 
are more often affected than the epiglottis. 

In this period was first advanced the idea of a 
transference of infection in phthisis from the lungs to 
the larynx by way of the nerve trunks, particularly the 
vagus (Friedreich: Handb. d. Spec. Path. u. Ther., 
Bd. V., 1854). This view was supported as late as 
1888 by Libermann (Be I'Etiologie de la Phthisie Put- 
monaire et Laryngee). 

While Friedreich totally misconceived the true basic 
facts of etiology, he attempted to differentiate between 
the tubercles in tuberculosis and the small gray no- 
dules due to simple inflammation of the mucosa. 

In the "Handbuch d. Spec. Path. u. Ther., Stuttgart, 
1856," Wunderlich showed the influence of Louis, and 
of Trousseau and Belloc, in his statement that the 
greater number of ulcerations occurring in the laryn- 
ges of tuberculous individuals are of a purely catar- 
rhal origin. 

He recognized the rarity of true tuberculosis of the 
trachea, and its comparatively frequent appearance in 
the larynx, especially in those cases where the lung 
disease is of long standing and accompanied by colos- 
sal secretions. 

Fourth Period : — The period of clinical study began 
with the demonstration of the practical utility of the 
laryngoscope, by the Maestro, Manuel Garcia, in 1855. 
(Physiol. Observ. on Human Voice.) 

During the preceding half-century many attempts 
were made to see into the interior of the larynx by 
means of variously conceived cannulae, mirrors and 
prisms, i. e. : Bozzini, 1807; Senn, 1827; Babbington, 



22 LARYNGEAL TUBERCULOSIS. 

1828 ; Beaumes, 1838 ; Liston, 1840 ; Trousseau aud Bel- 
loc, 1837; Warden, 1844; Tiirck, 1857, and Czerinak, 
1858. 

Many of these appliances were based upon the prin- 
ciple afterwards adopted by Garcia, but for various 
reasons failed of common adoption. 

Immediately following Garcia 's communication the 
science of clinical laryngology was born and advanced 
with giant strides, and laryngeal phthisis, so long mis- 
understood and obscured by a cloud of false ideas, 
emerged almost at once into the light, freed from most 
of the old misconceptions. 

The pioneer work was largely performed by C. Ger- 
hart (Gerhardt und Roth, Ueber Syphil. Krankheiten 
d. Kehlkopfes, Virch. Arch., 21, 1860) in detailing a 
large series of cases examined by the new method. In 
this thesis he clearly described syphilis and succeeded 
in finally separating it from phthisis. 

This work was soon supplemented by another upon 
the influence of catarrhal swelling of the posterior 
laryngeal wall in the production of aphonia. (Ueber 
einige Ursachen Katarrhal Heiserkeit, Wurzbiirger 
medic. Zeitschr., Bd. Ill, 1862.) 

In this essay he considered the possible influence of 
an apparently simple catarrh upon the development of 
tuberculosis, and believed that this condition might be 
of considerable etiologic import. 

In 1861, in the (l Tr. Clin. d. mal. d. enfant s, Rilliet 
and Barthez," we find the first reference in regard to 
the influence of age. They state that ulcerations in the 
upper respiratory tract occur usually after the seventh 
year of life, and very rarely before the age of three to 
four years, and that while usually dependent upon 



HISTOKY. 23 

advanced pulmonary disease, they may occur as a re- 
sult of other organic tuberculous processes. 

They agree with Louis as to etiology, and maintain 
the general dependence of laryngeal ulcers upon pre- 
ceding advanced disease of the lungs or other organs. 

To the theory of Eheiner, the mechanical injury of 
symmetrical points, Tiirck (Klin. d. KehlkopfkranJch., 
Wien, 1866), one of the most careful observers, reverts, 
and concludes that this is the most frequent form, while 
the true tuberculous ulcers occur in but a small propor- 
tion of cases. 

As late as 1872 we again find this idea of the non- 
tuberculous nature of many ulcerations advanced by 
Waldenberg (D. loc. Behandl. d. Krankheiten d. Ath- 
mungsorgane), who explains his conviction on the 
ground that many ulcers of the larynx in phthisical 
individuals heal completely, and are therefore merely 
follicular ulcerations. 

The earliest descriptions of the tuberculous tumor 
were given by Tobold (D. chron. ■KehlkopfkranJch., 
1866) ; Mandl (Tr. prat. d. mal. d. larynx et pharynx,, 
Paris, 1872) and Ariza (Anfiteatro, anat. Espanol, 
1877). 

The first of these described cases in the incipient 
stages of laryngeal tuberculosis where the entire glot- 
tis was filled with tumors of the mucosa. The growths 
were pale in color, of cauliflower formation, and ap- 
peared mainly in the ventricles, on the vocal processes 
and the posterior wall. 

Kindfleisch (LeJirb. d. Path. Anat., 1873) upheld in 
a slightly modified way the theory of Eheiner and 
Tiirck, i. e., the irritation of symmetrical segments of 



24 ■ LARYNGEAL TUBEKCULOSIS. 

the larynx by the infectious products of a scrofulous 
catarrh. The persistence of this idea has been shown 
at length, both because of its important place in history 
and because many more modern observers have given 
it a prominent place in etiology. 

In studying the further progress of knowledge it is 
necessary to revert to the role played by the tubercle. 

Lewin (Ueb. Krankh. einz. Theile d. Larynx, etc., 
Virch. Archiv. XXIV, 1862) believed some erosion of 
the mucosa to be an almost necessary antecedent to 
the deposit of tubercles, or at least that the tubercles 
usually develop in such damaged spots. 

That the tuberculous ulcer is a result of the disin- 
tegration of tubercles he clearly recognized, and like- 
wise the existence of small granulations about the 
edges of such ulcers, the first reference to this import- 
ant characteristic. 

Virchow (Geschwulste, 1864 and '65,) took strong 
exception to Louis's assertions regarding the 
mechanical cause of phthisical ulcers, and made it 
plain that laryngeal tuberculosis is due to the tubercle 
and nothing else, and reasserted the fact that ulcera- 
tion is consequent upon destruction of the tubercle. 

He recommended the larynx as the best locality in 
which to study the tubercle, which he described as fol- 
lows: "In the very frequent tuberculosis of the 
Larynx, small, flat, clear, grey or whitish swellings are 
found, which hardly project beyond the surface." 
These tubercles never caseate or form tumors. 

Ii. Meyer (1). gegenw. Stand, d. Fr. v. d. Kehlkopf- 
schwindsucht. Correspondenzbl. /. Schweizer Aerzte, 
Nr. 13, 1873) combatted this view of Virchow's as to 



HISTORY. 25 

the relation of the tubercle to ulcerative laryngeal 
phthisis, upon the ground that he had been unable to 
find tubercles in laryngeal ulcerations and that there- 
fore they could play no part in its production. Ten 
years later Bosworth reverted to the old theory of the 
non-tuberculous nature of some laryngeal lesions in 
phthisis. 

Almost coincidently with Virchow, Forster (Lehrb. 
d. path. Anat., 1864) expressed the same views, and 
gave as the favorite site of the tubercles the inter- 
arytenoid sulcus and described their ultimate con- 
version into crater-shaped ulcers, confluent, with se- 
quelae of cartilage necrosis and abscess formation. He 
believed the tubercle might be either primary or sec- 
ondary. 

Bruns (Die Laryngoskopie n. laryng. Chirurgie, 
1865) credited laryngeal ulcers to one of two sources: 

1. Disease of the mucous follicles. 

2. Circumscribed deposits in the submucosa (tuber- 
cles). 

The dependence of epithelial necrosis upon 
submucous deposits was further elaborated by Tobold 
(Laryngosk. u. Kehlkopfkranhh., 1867) who ascribed 
the necrosis to the gradually increasing pressure from 
beneath, with ultimate loosening of the mucosa from 
its attachment, or in some instances, to the degenera- 
tion of miliary tubercles. 

From this time on advance in the knowledge of 
pathology was rapid and unbroken, the chief work 
being done by E. Wagner, Waldenburg, Kindneisch, V. 
Ziemssen and Heinze. 

Wagner (D. Tuherkelahnl. Lymphadenom. Arch. f. 



26 LARYNGEAL TUBERCULOSIS. 

Heilk., 11-12, 1870 and '71) minutely pictured the 
typical tuberculous infiltrate, tubercle and ulcer. 

Waldenburg (D. loc. Behandl. d. Krankh. d. Ath- 
mungsorgane, Berlin, 1872) described the occurrence, 
about the edges of tuberculous ulcers, of miliary tuber- 
cles, but was uncertain as to whether they were the 
cause or a product of the ulcers. With many observers 
he agreed in considering a large proportion of laryn- 
geal ulcers in consumptives to be purely catarrhal, a 
conclusion based upon the rapidity with which some 
of these ulcers healed. 

A new view point was assumed by Sommerbrodt 
(Ueb. d. Abhangigk. phthisis cher Lungenerkrankh. v. 
prim. Kehlkopfaffectionen, Arch. f. Exper. Path. u. 
Pharni., 1873) in his contention that pulmonary 
phthisis might be caused by purulent peribronchitis 
acting through a chronically inflamed larynx and tra- 
chea. 

V. Ziemssen (Handb. d. spec. Path. u. Ther., Bd. IV, 
1, 1876) classified tuberculous laryngeal ulcerations 
as follows: 

1. Ulcerations due to miliary tuberculosis and tu- 
berculous inflammations consequent upon pulmonary 
phthisis. 

2. Follicular ulcerations. 

3. Ulcers dependent upon specific cell infiltration. 

4. Superficial aphthous, or erosion ulcers. 

lie likewise maintained the usual dependence of 
laryngeal ulcerations upon disease of the lung? and 
claimed that healing, while possible, was extremely 
rare. 

Fifth Period: — The credit of reconciling these many 



HISTORY. 27 

conflicting conjectures belongs to Oscar Heinze, who 
in 1879, (D. KehlkopfschwindsucM, Leipzig) demon- 
strated that the sole cause of laryngeal and tracheal 
tuberculosis is tuberculous infiltration of the mu- 
cosa, and that ulceration in the larynx and trachea 
never leads to tuberculosis unless there is simultaneous 
or subsequent tuberculosis of the mucous membranes. 

This view was subscribed to by all the later investi- 
gators except Beverly Robinson (Ulcerative Phthisi- 
cal Laryngitis, Amer. Jour, of Med. Sciences, April, 
1879) who claimed that "the ulcerations which have 
been described in the larynx under the name of miliary 
tubercles are none other, as a rule, than small spheri- 
cal swellings, which are occasioned by the filling up 
with transparent fluid of the closed follicles of the 
submucous reticulum, which have been described by 
Heitler and Coyne." 

Heinze believed in the simultaneous existence of 
tuberculous and catarrhal ulcers. 

Sixth Period: — The record of advancement in ther- 
apy is meager. Galen (129-200 A. D.) declared that 
ulcers of the i ' arteria aspera" were easily curable, but 
this impression was combatted by Marcellus Donatus 
(De Historia Medica Mirabili Lib., 1613) and his 
views, in so far as they concern tuberculosis, have ob- 
tained until the present time. 

During this entire period but few procedures were 
offered for relief through either surgical or medicinal 
agencies. 

In 1818 it was suggested that some benefit followed 
the use of creosote in the form of tar fumigations. 



28 LARYNGEAL TUBERCULOSIS. 

Albers, in 1829, (Die Path. u. Ther. der. Kehlkopf- 
krauklieiten) advocated the performance of trache- 
otomy and claimed for it a wonderful influence through 
the complete rest given the larynx. 

The use of steam inhalations, swabbing, douches 
and the auto-insufflation of powders was advised by 
Trousseau and Belloc in 1837. 

A year later Horace Green succeeded in making ap- 
plications of silver nitrate to the interior of the 
larynx, by means of curved applicators similar to 
those in use at the present time. His report was pub- 
lished in 1846 under the caption: "Treatise on Dis- 
eases of the Air Passages, comprising an Inquiry into 
the History, Pathology, Causes and Treatment of those 
Affections of the Throat called Bronchitis, Chronic 
Laryngitis, Clergyman's Sore Throat, etc." Green's 
pretensions were bitterly denounced by the profession, 
the greater number claiming such a procedure to be 
absolutely impracticable. Finally, after suffering the 
severest of calumnies, he succeeded in proving his 
claims and in having the method of treatment upheld. 

William Marcet (Clinical Notes on Diseases of the 
Larynx, London, 1869) advocated puncture of the 
involved tissues, but the surgical treatment received no 
further impetus until the resurrection of Albers' 
suggestion of the utility of tracheotomy, by Moritz 
Schmidt, in 1880 (Die Kehlkopfschu-'nidsitclil und ilir<> 
Behandlung, Arch. f. Klin. Medicin., Bd. 25, 1880). In 
addition to tracheotomy he strongly recommended, in 
selected cases, the use of scarification and incision of 
the laryngopharyngeal wall. 

Surgery, however, owes its present recognized posi- 



HISTOKY. 29 

lion to the work of Heryng (Beitr. z. chir. Beliandl. d. 
tubercul. Larynxphtliise. d. Med. Woch., 1886, and 
Die Heilbarkeit der Larynx phthisie und Hire Chir- 
urgislie Beliandlung, 1887), who advocated curettage 
and claimed to have effected many cures through its 
performance. 

Two years before this, Krause {Berlin Klin. Woch- 
enschrift, Nr. 26, 1885) introduced lactic acid and re- 
ported many favorable results. Consequent upon these 
two recommendations the pendulum swung from the ex- 
treme pessimism that had ruled from earliest times, to 
enthusiastic optimism, to recede once again to an illogi- 
cal point when the high promises regarding the univer- 
sal utility of these agents remained unfulfilled. 

Lactic acid, however, is still recognized as one of the 
most valuable agents for combatting ulceration, and 
the surgical treatment has steadily gained in favora- 
ble consideration, especially upon the Continent. In 
America, with a few notable exceptions, it has failed 
to secure the endorsement it undoubtedly deserves, 
although at the present time there seems to be some 
recrudescence in its favor. 



CHAPTER II. 
ETIOLOGY. 



The upper respiratory tract, owing to its anatomical 
position, relationships and conformation, exhibits in 
certain segments a marked susceptibility to infection 
by the tubercle bacillus. The results of this infection 
become manifest in any or all of the protean forms of 
the disease recognized as typical in other organs — in- 
filtrations, granulations, ulcerations, tuberculomata, 
miliary tubercles and lupus. 

THEORY OF PRIMARY AND SECONDARY 
INFECTION. 

The chief contention from an etiologic standpoint 
concerns the route by which the tubercle bacillus, the 
invariable causative agent, gains entrance into the 
tissues. 

Two theories are advanced, the one of primary in- 
fection depending upon the assumption of an initial 
lesion of the nose, pharynx, or larynx as the case may 
be, the infecting material being deposited by the in- 
vested food or inspired air; the other assuming- a pri- 
mary involvement of some distant organ, usually the 
Lungs, with an infection of the upper tract through the 



PEIMAEY AND SECONDARY INFECTION. 31 

agency of bacilli-laden sputum, or by way of the blood 
or lymph vessels. 

In so far as the larynx is concerned, the possibility 
of an occasional primary infection has apparently been 
proven by the post-mortem investigations of Orth, Po- 
grebinski and Demme, in cases where, with undoubted 
laryngeal tuberculosis, the lungs were found to be en- 
tirely normal. 

These cases, in connection with a few others of a 
less definite nature, would be absolutely conclusive 
were it not for one factor which may invalidate previ- 
ously accepted conclusions — the possibility of infection 
of the larynx by way of the lymphatic glands. 

Latent tuberculosis of any of the constituent parts 
of the lymphatic system, particularly of the tonsils 
and bronchial glands, may exist for years without 
symptoms or alterations in their macroscopic images, 
and yet from such foci, through lymphatic or blood 
transmission or perhaps by direct transmission 
through the tissue spaces, a secondary laryngeal focus 
might become established, particularly if the involved 
gland has been subject to traumatism or to the action 
of such inflammatory processes a scarlet fever and mea- 
sles. That such a nidus, even when situated within the 
the interior of the gland, may become the point of de- 
parture for other widely disseminated processes has 
been repeatedly demonstrated. 

Cornet has seen general miliary tuberculosis follow 
an experimentally induced focus of small size in such 
a lymph gland, and various observers, notably Volland, 
have witnessed the invasion of the lung by bacilli from 
the cervical glands. 



32 LAKYNGEAL TUBEKCULOSIS. 

Tuberculous peritonitis lias been known to have its 
origin in a tonsillar lesion, and Shurley, in considering 
this source of infection says : "Much enlarged adenoid 
glands at the vault of the pharynx, especially with dis- 
eased conditions of the follicles or lymph spaces, are 
often conducive to the accession of pulmonary dis- 
eases.'' 

The relations of the lymphatics of the larynx to 
neighboring structures need not be considered for in- 
fection does not invariably follow in the direction of 
the lymph current; it may take a course vertical or 
directly opposed to it. 

Upon this point Cornet writes : "Dissemination from 
the primary gland takes not only a centripetal, but 
also a radial direction, in such wise that the main 
movement sets in toward the heart, along with the 
lymph current; that minor movements take a course 
vertical to that of the lymph current ; finally, that there 
is a slight tendency, often imperceptible or even en- 
tirely lacking, to spread in a direction opposed to that 
of the lymph current." 

Invasion may also occur through the tissue spaces 
without leaving trace of its passage. 

The frequency of this latent lymphatic condition is 
shown by a study of recent statistics. 

In forty cadavers, thirty of which during life had 
shown no signs of tuberculosis, Pizzini found latent 
disease of the bronchial glands in 42 per cent. 

Cornet found the same conditions in four, and Spong- 
ier in six children who had died of diphtheria, sepsis 
and peritonitis. 



PEIMAKY AND SECONDAKY INFECTION. 



33 



Jackson (Boston Med. and Surg. Journal, May 12, 
'04) reported the following: 

18 cases — Tuberculous meningitis. 

1 case — No history obtainable. 

2 cases — Tuberculosis found on general examination. 
14 cases — No history of tuberculosis. 

AUTOPSIES. 

16 cases — Evidence of chronic tuberculosis. 
9 cases — Pulmonary tuberculosis. 
7 cases — Tuberculous bronchial glands. 

Demme claims that these glands, i. e., the bronchial, 
are diseased in 80 per cent of all cadavers, and Neu- 
mann found them involved eight times in 105 autop- 
sies upon children supposedly non-tuberculous. 

Examinations of the tonsils show equally surprising 
results. In studies made of apparently healthy or hy- 
pertrophied tonsils, from subjects not known to have 
had tuberculosis, the following results were tabulated: 



AUTHOR. Cases. 

Lermoyez 32 

Gottstein 33 

Brindel 64 

Lartigan and Nlcoll 75 

Wright 63 

Pluder & Fischer 32 

Pilliet 10 

Broca 100 

Dieulafoy 61 

Dieulafoy 35 

Ruge 18 

McBride & Turner 100 

Cornil 70 

Dempel 15 

Piffl 100 

Lewin 200 

Schreiber 29 

Hynitsche 180 

Friedmann 145 

Tarchetti & Zanconi 17 

Baup 45 

Ito 10 

Rethi 100 

Maccayden & MacConkey 78 

Wex 210 

Theissen 45 

Lathan 45 

Lockard 74 

1,986 



Tonsillar 

Involvement: 

Pharyngeal and 

Faucial. 

2 

4 

8 
12 



5 

3 



8 

7 

6 

3 

4 

1 

3 
10 

2 

7 

6 



1 



6 



7 

2 

7 

5 

119=5.9% 



34 LAKYNGEAL TITBEKCULOSIS. 

In tuberculosis of the cervical glands it is estimated 
that 90 per cent of the infections originate in the ton- 
sils. 

Friedmann makes the following tabulation of 91 
tonsils examined post-mortem, taken (with one excep- 
tion) from subjects under five years of age: 

1 tonsil - - - Riddled with tubercles. Bacilli present 

in large numbers. No other lesions 
in body. 

4, and probably Tonsillar tuberculosis probably pri- 
5 other cases - mary. Partly complicated by sec- 
ondary involvement of glands, in- 
testines and bones. 

7 other cases - Giant cells but no bacilli. 

2 other cases - Tuberculosis present, but not primary. 

3 other cases - Giant cells, but condition not tuber- 

culous. 

8 cases - - - General tuberculosis without tonsil- 

lar. Old scars in tonsils, the result 
of early tuberculosis. 

2 other cases - Similar but less distinctive results. 

4 cases - - - Internal without tonsillar tuberculosis. 

3 cases - - - Bacilli found in smears from surface 

of tonsils, but no tuberculous 
changes found. 

Baup, in 841 cases, including 48 of his own, found 
53, or 6 per cent, tuberculous. 

Eethi found bacilli present in six of 100 hypertro- 
phied tonsils removed from persons showing no signs 
of tuberculosis. 

Walsham, in 34 autopsies on patients dead of tuber- 
culosis, found the tonsils tuberculous in 20. 

Babes, in the Children's Hospital at Budapest, dis- 
covered tuberculosis of the lymph glands, particularly 
of the mediastinum and bronchi, in more than one- 
half of the autopsies. 



PKIMAKY AND SECONDARY INFECTION. 35 

Strassmann, in 21 autopsies upon phthisical sub- 
jects, demonstrated tonsillar involvement in 13. 

The author, in 74 tonsils from subjects showing no 
signs of tuberculosis, found five tuberculous. The 
removal of one of these was followed by the accession 
of the disease in the cervical lymphatics and larynx. 

From an examination of the tonsils of 200 subjects, 
L. Lewin makes the following deductions : 

1. Hyperplastic pharyngeal tonsils conceal tuber- 
culous lesions in about 5% of the cases. 

2. The tuberculosis is present in the so-called tumor 
form, and is characterized by the absence of surface 
indications of its presence. 

3. This latent tuberculosis may apparently be the 
first and, indeed, the only localization of the disease in 
the individual. 

4. It is generally, however, associated with other 
tuberculous processes, generally of the lungs, which 
may, however, not have developed at the time the ton- 
sil was operated upon. 

5. It is a comparatively frequent condition among 
those suffering from tuberculosis of the lungs. 

6. It is found in the normal-sized tonsil as well as 
the hyperplastic. 

These few cases previously cited (Orth, Demme, Po- 
grebinski), culled from the entire voluminous literature 
and quoted by all authors as the most typical upon 
which to base the claim of occasional primary localiza- 
tion of the tuberculous process in the larynx, cannot 
therefore be accepted as definitely establishing the sup- 
position without further confirmatory evidence, for not 
only must lesions of the lungs be excluded but of the 
lymphatic system as well. In the above cited cases no 
cognizance was taken of this condition. Neither is 



o 



6 LARYNGEAL TUBERCULOSIS. 



this evidence, i. e., absence of lymphatic as well as of 
pulmonary involvement, afforded by other reported 
instances. 

M. Schmidt says : " I have myself seen a number of 
such cases of primary involvement, especially in the 
form of tumors of the ventricular bands and cords, but 
also as ulcerations. ' ' Yet none of these cases were sub- 
stantiated by post-mortem examination. 

Numerous other observers, among whom may be 
mentioned Dehio, Neidert, Fischer, Cadier and Gleits- 
mann, have maintained the principle of primary inoc- 
ulation, based upon the observation of patients where 
no pulmonary lesion was manifest or in whom it devel- 
oped only late in the course of the laryngeal disease. 
This last author, after citing two cases of cured laryn- 
geal tuberculosis where involvement of the lungs was 
never clinically demonstrated, makes the admission 
that : "Obviously, if the postulate is brought forth that 
nowhere in the lungs the smallest tuberculous area 
exists, then the occurrence of primary laryngeal tuber- 
culosis cannot be any longer maintained, neither in the 
dead nor much less in the living. But, for my part, I 
do not see the rationale of the argument to demand the 
abstract absence of the disease, in this instance of the 
lung, to be able to believe in the existence of another, 
viz., primary laryngeal tuberculosis. " 

It is here we have the crux of the question. Is pri- 
mary infection capable of proof when other foci exist? 

Central lesions of the lung, old partially cicatrized 
areas and new cheesy deposits in the lymph glands, 
bones, kidneys or retroperitoneal tissues, frequently 
escape the most careful search and cannot be demon- 



PRIMARY AND SECONDARY INFECTION. 37 

strated except upon the cadaver, yet such lesions may 
develop, remain unrecognized, give rise to other infec- 
tions and cicatrize, or later, under fortuitous circum- 
stances, recur. 

The frequency of such lesions of the lungs has been 
shown by Birch-Hirschf eld : 

Autopsies, 3,0G7; Pulmonary Tuberculosis, 41.86%; 
Tuberculosis cause of death, 23.3%; Old Cicatrized 
Pulmonary lesions, 11.97%; very early lesions, 2.8%. 

When cicatrization has occurred the age of the 
lesion cannot be definitely ascertained, and upon this 
ground we must refuse to accept the evidence of such 
cases as those quoted by Trifiletti and Josephsohn. 

The former reported the case of a girl of twenty-one 
years with tuberculous infiltration of the laryngeal 
mucosa and apparently healthy lungs, who eight 
months later showed the first signs of pulmonary 
involvement. 

In Josephsohn 's case the evidence of lung involve- 
ment arose two years after laryngeal phthisis was 
diagnosed. Similar and equally indefinite cases are 
reported by Ziemssen, Barth, Haslund, Garre and 
Moritz. 

Bernheim refers to twenty-nine cases of primary 
laryngeal disease seen by him, without post-mortem 
confirmation. That such a large number of apparently 
primary cases should be seen by one observer is re- 
markable when we consider the paucity of cases from 
all other sources. 

J. Home has not once in ten years met with an exaim. 
pie in the necropsies of nine large hospitals. 

In 904 consecutive cases for which exact records are 



38 LARYNGEAL TUBERCULOSIS. 

available, the author has met but three in which the 
lung examination proved negative and in one of these 
the necropsy revealed a healed lesion. In a second 
case, one of slight laryngeal involvement in which 
death could not be attributed to the tuberculous pro- 
cess, the lungs were normal but the faucial tonsils 
were affected, showing the possible dependence of some 
laryngeal cases upon old lymphatic lesions. The third 
case could not be subjected to autopsy. 

An oft-quoted case is that of Champeaux's, where 
a tumor was present on the ventricular band, with 
apical dullness, but no bacilli in the sputum. That such 
a case is absolutely without value in this connection 
goes without saying. 

Sheedy (Post Graduate, XVIII, p. 164) reports a 
case in which the larynx was involved for nine months, 
with bacilli in the sputum, before the lungs became 
affected. 

Kelson (Laryngoscope, April, 1903) presented be- 
fore the Laryngological Society of London a man with 
swelling of the epiglottis, ary-epiglottic folds, ventricu- 
lar bands and vocal cords, but no bacilli in the spu- 
tum. 

To establish proof of this supposition, i. e., the possi- 
bility of involvement of the larynx by way of the lym- 
phatics or blood vessels from the lymph glands, or by 
direct transmission through the tissue spaces, the fol- 
lowing facts and somewhat parallel cases are adduced : 

' ' Caries of the processus mastoideus and of the pet- 
rous bone are mostly referable to tuberculous disease 
of the middle ear through the lymphatic channels. A 



PEIMAKY AND SECONDARY INFECTION". 39 

bony focus originated through infection by way of the 
pharyngeal tonsils. ' ' — Euge. 

"In an infection proceeding by way of the vascular 
system, it is of course immaterial where the primary 
focus is situated:'' — Cornet. 

In 67 autopsies (Konig-Orth) lesions of the bones 
or joints were found to be dependent upon other lesions 
in 53 cases — 79 per cent. Of these the lungs were re- 
sponsible in 37 cases, the glands in 21. 

Ph. Schech reports the case of a man who in his 
sixty-third year had the right testicle removed because 
of tuberculous involvement. He remained free from 
the disease for two years, when the posterior pharyn- 
geal wall became affected ; then the larynx, and finally 
the lungs succumbed. 

Another example given by the same author concerns 
a man who in his twenty-eighth year developed tuber- 
culosis in the left apex with hemoptysis. After fifteen 
years of seemingly perfect recovery he suddenly devel- 
oped tuberculosis of the ear, velum and lips. 

"Laryngeal tuberculosis may be caused by lymphatic 
transmission from a neighboring focus, i. e., in the 
palate, fauces or tonsils." — Cornet. 

Chiari and Eiehl examined 68 persons who suffered 
from lupus either of the face or of the mucous mem- 
branes, but gave no subjective symptoms of laryngeal 
disease, and discovered lupus of the larynx in six cases. 

It has been proven that a tuberculous process of the 
larynx itself becomes a source of further infection, 
either by contact, as of symmetrical portions of the 
larynx, or by lymphatic extension to neighboring 
organs, either of the mouth or pharynx. If mouth in- 



40 LARYNGEAL TUBERCULOSIS. 

fection can result by lymphatic transmission from the 
larynx the converse mnst likeswise be true, as infec- 
tion occurs not only in the direction of the lymph cur- 
rent but in a direction directly opposed or vertical 
to it. 

In a number of instances a retrograde infection — of 
the tonsils from diseased cervical glands — has been 
demonstrated to have taken place. 

Grunwald (Diseases of the Larynx, 1900) remarks : 
" There is no doubt that diseased cervical glands are 
capable of infecting the larynx; many a so-called i pri- 
mary' case is no doubt due to this cause.' ' 

Two cases proving connection between disease of the 
larynx, cervical glands and tonsils, occurring in the 
author's practice, may be adduced: 

Girl, aet. 11. Hypertrophied tonsils and small mass of 
adenoids. Bilateral enlargement of the cervical 
glands. Lungs normal and general condition good. 
Three months following the removal of the adenoids 
and tonsils, the cervical glands having in the meantime 
partially disappeared, hoarseness developed and 
examination revealed incipient tuberculosis of the left 
side of the larynx. The left cord was infiltrated 
throughout its entire extent and there was moderate 
infiltration of the inter-arytenoid sulcus. The fur- 
ther history substantiated the diagnosis, but pulmon- 
ary tuberculosis was never demonstrated. In this case 
we had an undoubted infection of the cervical glands 
from the tonsils, and of the larynx by way of the cervi- 
cal glands. Examination of the tonsils had proved 
them tuberculous. 

The second case concerns a girl of seven years, who 



PRIMARY AND SECONDARY INFECTION. 41 

had a large mass of suppurating cervical glands on the 
right extending from the angle of the jaw to the clavi- 
cle. The immediate cause of the consultation, how- 
ever, was a retro-pharyngeal abscess of three days' 
duration. The tonsils were not large, but ragged, with 
numerous deep crypts filled with cheesy concretions. 
The lungs and other organs were apparently normal. 
The retro-pharyngeal abscess was opened, draining 
almost completely the mass of suppurating cervical 
glands. Ten days later these glands were removed 
and two weeks later the tonsils were completely extir- 
pated, and on microscopic examination showed un- 
doubted tuberculosis. At this time the first complete 
laryngeal examination was made, the child having 
previously rebelled. There was rugous infiltration of 
the interarytenoid sulcus, with a small ulcer at the 
point of union of the arytenoid cartilage, vocal cord 
and right ventricular band. Seven months later the 
child died and examination showed the lungs to be 
normal and the larynx tuberculous. 

This case is of special interest from another stand- 
point; the cervical suppuration antedated the pus for- 
mation in the retro-pharynx, burrowed its way into 
that space, and was partially emptied through the phar- 
yngeal incision. 

McKinney (Journal of Tuberculosis, January, 1903) 
reports a case of laryngeal tuberculosis secondary to 
tuberculous cervical glands, and it is the generally ac- 
cepted belief that in the great majority of the cases of 
pulmonary tuberculosis occurring in children, infection 
takes place from the lymph nodes ; the latter may be 
infected in many ways. There is no certain relation 



42 LARYNGEAL TUBERCULOSIS. 

between the points of entrance of the infection and the 
points of development of the disease. 

Lartigan and Nicholl (American Journal Medical 
Sciences, June, 1902) after long research, concluded 
that primary tuberculosis of the pharyngeal tonsils is 
probably more common than is generally supposed in 
the production of either localized or general infection. 

Upon this subject Cornet says: " Since the as- 
sumption of a primary disease, i. e., of the larynx, de- 
pends very largely upon the absence of demonstrable 
signs of disease in the other organs, especially the 
lungs, intra vitam, we should be very guarded, in view 
of the imperfections of our methods of clinical re- 
search, in inferring the primary nature of the disease. ' ' 

As proving the uncertainty of the source of infec- 
tion he refers to a case, classified as primary pharyn- 
geal, reported by Isambert, of a boy of four and a half 
years who had tuberculous ulceration of the velum 
without signs of pulmonary involvement. He had, how- 
ever, in early infancy shown signs of scrofula and 
"scrofulous (?) coryza." 

Pulmonary phthisis frequently develops from dis- 
ease of the cervical glands; the glands, in the majority 
of instances, owe their infection to previous disease 
of the tonsils and doubt no longer exists as to the occa- 
sional spread of the process from the cervical glands, 
and probably from the bronchial glands as well, to the 
larynx. 

In view of the above proven facts, these frequently 
cited cases of Orth, Pogrebinski, Demme and others, 
can no longer be held to indisputably prove the occur- 
rence of primary tuberculous infections of the larynx. 



PEIMAEY AND SECONDARY INFECTION. 43 

The probability of a direct infection of the larynx 
from without is extremely doubtful, although upon 
purely theoretical grounds the possibility must be 
admitted. 

While the bacilli-laden air in its passage through the 
nose and naso-pharynx is freed from the greater num- 
ber of contained organisms and dust, a small propor- 
tion penetrates into the larynx and bronchial tubes. 
The larger part of those introduced in this man- 
ner, and not passing onward into the lungs, is imme- 
diately expelled by the upward motion of the cilia 
that exist everywhere in the larynx except upon the 
vocal cords and posterior wall. At these points the 
dust particles to which the bacilli are generally at- 
tached cause an increase in the normal secretions 
which aid in the expulsion. When, however, owing 
to previous inflammations of the mucosa, erosions exist, 
the reflex irritability is abnormally low and many of 
the organisms may be retained and gain entrance 
through these breaks in continuity. The abraded con- 
dition of the mucosa is not always essential as it has 
been demonstrated that the bacilli may penetrate intact 
membranes, or even pass through the ducts of glands, 
as will be shown in discussing the etiologic role of the 
sputum. 

If infection by inhalation plays an important role in 
etiology as many observers would have us believe, 
would it not be natural to conclude that laryngitis 
would occur in a larger proportion of those people who 
live under unhygienic surroundings and follow un- 
healthful occupations, than of those not subject to these 
disadvantages'? A statistical study of these patients, 



44 LARYNGEAL TUBERCULOSIS. 

however, shows that the relative proportion of laryn- 
geal to pulmonary cases is no larger in the so-called 
unheal thful than in the favorable avocations, and that 
the same proportion maintains between individuals liv- 
ing in the rural communities and in the congested areas 
of the large cities. 

If laryngeal tuberculosis occurred as a primary in- 
fection there would undoubtedly be more positive evi- 
dence in its support. When but a few cases can be 
adduced from such voluminous reports as are now ac- 
cessible, and these take into account the condition of 
the lungs only, it practically removes the question be- 
yond the pale of serious consideration. It is the almost 
universally accepted dictum that an absence of pul- 
monary foci establishes the primary nature of any ex- 
isting laryngeal infection, whether or not there are foci 
present in other organs, but such a conclusion is abso- 
lutely unwarranted. Thus, in referring to primary 
laryngeal tuberculosis, Richard Lake says : 

"As already mentioned, the author has seen two 
cases in which the larynx became affected secondarily 
to an apparently primary tuberculous otitis media, and 
in which the signs of the disease in the lungs did not 
show themselves until considerably later.' ' — Laryngeal 
Phthisis, p. 93. 

These cases he classified as "primary laryngeal." 

A somewhat parallel case, classed as primary laryn- 
geal tuberculosis, in which a child of four and a half 
years, dead of tuberculous meningitis, was found to 
have a laryngeal ulcer containing bacilli, is recorded by 
Demme. 

From a purely practical standpoint, thai is from a 



PEIMAKY AND SECONDARY INFECTION. 45 

prognostic and therapeutic point of view, a tuberculous 
lesion of the larynx may be considered primary when 
there is no demonstrable evidence of pulmonary or 
other organic involvement, but while theoretical con- 
siderations point to the possibility, and even the proba- 
bility of such an occurrence (for there is no special 
peculiarity of the laryngeal mucosa or secretions to 
prevent it from becoming infected) we have as yet no 
indisputable evidence to establish it as an abstract fact. 

EESUME. 

1. The absence of pulmonary disease alone does not 
establish the primary nature of tuberculous laryngeal 
disease. 

2. Lymphatic involvement, especially of the tonsils 
and cervical glands, must likewise be excluded. 

3. The tonsils are tuberculous in perhaps five per 
cent of the cases in which hypertrophy exists. 

4. It is found in the normal-sized tonsils as well as 
in the hyperplastic. 

5. The dependence of some laryngeal cases upon 
disease of the tonsils and cervical glands has been 
clinically demonstrated. 

6. Infection of the lymphatics usually follows in the 
direction of the lymph current, but may spread in a 
direction opposite, or vertical to it. 

7. It may also travel through the tissue spaces. 

8. But a few cases are recorded, substantiated by 
post-mortem investigations, in which, with lesions of 
the larynx the lungs have been found normal, and in 
these instances no reference is made to the condition 
of the lymphatic system. 



46 LARYNGEAL TUBERCULOSIS. 

9. There is no inherent peculiarity of the laryngeal 
mucosa or its secretions to prevent it from becoming 
primarily infected. 

10. This occurrence, however, has not been demon- 
strated, despite the fact that phthisis is the most com- 
mon and widespread of all serious laryngeal diseases. 

11. From a practical standpoint, a case may be 
considered primary if there is no demonstrable disease 
of the lungs. 

12. Until a case of laryngeal phthisis, unaccom- 
panied by either pulmonary or lymphatic disease, has 
been proven, the assumption of primary infection can- 
not be maintained. 



CHAPTEE III. 



ENDOGENETIC AND EXOGENETIC INFECTION. 



While the usual and probably sole form of laryngeal 
phthisis has been shown to be the secondary one, opin- 
ions as to whether infection can be attributed to the 
direct effect of bacilli-laden sputa or to hematoge- 
nous and lymphatic deposit, diverge as widely as upon 
the primary question. The majority of morbid anato- 
mists look upon sputal infection as the predominant 
cause, while the clinicians, with few exceptions, con- 
sider the blood and lymphatic vessels to be largely re- 
sponsible. Neither school claims that the cause advo- 
cated by it is the exclusive one and thus it becomes a 
question of determining which factor is active in the 
greater number of instances. The entire domain of 
laryngology presents no problem of greater complex- 
ity, for almost every fact adduced in favor of one or 
the other theory is subject to various interpretations. 

In support of the theory of infection by hematogen- 
ous or lymphatic deposit we have the fact that 
the laryngeal process is usually most marked upon the 
side where the pulmonary disease is farthest advanced, 
or in unilateral pulmonary involvement, the laryngeal 



48 LARYNGEAL TUBERCULOSIS. 

infection is in the majority of instances npon the cor- 
responding side. Many observers, however, have de- 
nied this localization, thus Jurasz (Krankheiten der 
oberen Luftwege) found only 7.9 per cent of 378 cases 
which were unilateral and corresponding. 

Walsham (Channels of Infection in Tuberculosis) 
denies the frequent occurrence of lateralization, and 
Magenau (Archiv. fur Laryngologie, Bd. IX, 1899) in 
400 cases, found but 85 that were unilateral, and of 
these only 26, or 40 per cent, corresponded to the in- 
volved lung. 

On the other side there is the authority of such ob- 
servers as Schrotter, Schech, Friedreich, Shaffer and 
Krieg. 

Krieg (Archiv. fur Laryngologie, Bd. VIII, 1898) 
in 700 cases, found that in 275 the disease was unilat- 
eral, and in 252 of these, or 91.6 per cent, the pulmon- 
ary and laryngeal lesions were upon corresponding 
sides. 

In 114 cases at the Agnes Memorial Sanatorium, 
there were 31 of unilateral laryngeal involvement, and 
of these 22, or 70 per cent, corresponded to the side of 
greater pulmonary involvement. 

The author, in 904 cases, met with the following: 

Laryngeal lesions unilateral in 203 cases, of which 
139, or 68.4 per cent, corresponded to the pulmonary 
disease. 

In 207 additional cases the greater involvement was 
upon that side where the pulmonary process was most 
advanced. 

To offset this strong evidence of endogenetic infec- 



ENDOGENETIC AND EXOGENETIC INFECTION. 49 

lion, two explanations have been offered as to its 
probable cause: 

(1) As the primary symptom of a developing tuber- 
culous laryngitis, before other demonstrable laryngeal 
or pulmonary symptoms have developed, there has oc- 
casionally been observed a unilateral paresis of the 
cords with intermittent hoarseness. This has been 
followed by other signs of local infection and finally 
by the appearance of pulmonary symptoms. 

SchafTer reports having fond this paresis, after 
long observation and careful search, in 74 of 110 cases, 
a percentage of 67. The phenomenon has been ex- 
plained by the assumption of incipient tubercles of the 
apex, not clinically demonstrable, pressing upon the 
recurrent nerve or to like action upon the part of en- 
larged bronchial and tracheal glands. 

E. Frankel (Virch. Arch., LXXI, p. 261) attributes 
it in some cases to atrophy of the muscular fibres, with 
waxy or fatty degeneration. In some instances it may 
be due to an inflammatory process in the nerves them- 
selves, the so-called "tubercular pseudo-neuroma." 

The paretic condition results in loss of tone in the 
corresponding half of the larynx, resultant stagnation 
of the secretions and increased susceptibility on the 
part of the mucosa to infection by the sputum. 

While this cause may be active in a small proportion 
of the cases it does not occur with sufficient frequency 
to invalidate the claim of an endogenetic source in the 
majority of instances, for apart from SchafTer, few 
laryngologists have witnessed it save as a rare phe- 
nomenon. The author has seen it in less than five per 



50 LARYNGEAL TUBEECULOSIS. 

cent of his cases in which unilateral involvement of 
corresponding sides developed. 

(2) It has been assumed that the entire side of the 
body upon which the lung infection originates is con- 
stitutionally predisposed and weakened, and that there- 
fore the corresponding side of the larynx is first 
invaded. 

The histologic findings have generally been inter- 
preted as proving infection from within, i. e., by way 
of the blood or lymph vessels. 

The first macroscopic alterations in cases of laryn- 
geal tuberculosis are points of more or less circum- 
scribed swelling covered by healthy mucous membrane. 
Histologically these swellings are found to be subepi- 
thelial tubercles, the epithelium itself and an interven- 
ing zone of varying thickness remaining entirely 
normal. 

The distribution of the bacilli corresponds closely to 
the arrangement of the infiltrated tissues, decreasing 
in number from within out and entirely disappearing 
as the epithelial layer is reached. 

The subepithelial distribution of the tubercles and 
bacilli, while strong corroborative evidence of endo- 
genetic infection cannot be accepted as conclusive 
proof, for it has been experimentally proven that the 
bacilli can penetrate normal mucous membranes and 
even lymph glands without leaving trace of their en- 
trance or passage. 

The bacilli, having reached the subepithelial layers, 
would naturally multiply with great rapidity and thus 
lead to the conclusion that they had been deposited 
from within, as was done by Korkunoff (D. Arch. f. 



ENDOGENETIC AND EXOGENETIC INFECTION". 51 

Klin. Med., Bd. XLV) Heinze (KehlkopfscliivindsucM, 
Leipzig) and others. 

Various feeding experiments in animals have shown 
that the bacilli may penetrate the walls of the gut, and 
even the skin does not offer an impenetrable barrier 
for its inunction with infected sputum has been fol- 
lowed by various tuberculous changes. 

Jonathan Wright, of Brooklyn, in a drawing 
of a section, has shown in clearest manner the passage 
of bacilli through the intact epithelium. 

The subepithelial distribution of the tubercle bacilli, 
according to E. Frankel, is not typical. In an exami- 
nation of sixteen tuberculous larynges he found as 
many bacilli upon the epithelial surface as within the 
center of the ulcer, and from this argued invasion by 
way of the epithelium. 

The majority of his observations were made upon 
ulcerative cases and therefore have little weight, for 
they concern those cases either admittedly due to con- 
tact infection — the so-called "arrosion" ulcers — or 
subepithelial tubercles that through growth and degen- 
eration have destroyed the epithelial layers with su- 
perficial spreading of the bacilli. 

Moreover, of eighteen cases examined, fourteen show- 
ed streptococci and staphylococci, and he states that he 
invariably " found tubercle bacilli in deeper layers of 
the tissue than the pyogenic germs," showing con- 
clusively, despite his former negation, that the tubercle 
bacilli are found chiefly below the epithelial surface. 

The strongest proofs concerning the infective role 
of the sputum are afforded by two well-known phe- 
nomena ; the localization of the infected areas and the 



52 LARYNGEAL TUBERCULOSIS. 

occurrence of the so-called "arrosion," corrosion, or 
diphtheritic ulcers. 

(1) The fact is easily demonstrable that the seg- 
ments of the larynx most commonly affected are those 
most subject to irritation by the passing secretions. 
The following table shows the comparative frequency 
with which the various areas are involved, although 
some slight discrepancies will be noted in the reports 
of the different observers : 

Gaul Mackenzie Lake Lockard Phipps Inst. Total 

Vocal Cords 53 230 221 450 43 997 

Posterior Wall 36 196 174 640 35 1,081 

Arytenoid Cartilages 17 449 168 270 36 940 

Ventricular Bands.. 5 113 176 169 22 485 

Epiglottis 27 186 82 127 14 436 

Subglottic Space... 2 ... 38 15 .. 55 

Total 140 1,174 859 1,671 150 3,994 

From this large series of cases it is seen that the 
regions most frequently involved are the vocal cords, 
the posterior wall and the arytenoid cartilages. 

The vocal cords, owing to their exposed position and 
to the absence of ciliated epithelium, are almost con- 
stantly bathed with the tenacious pulmonary secre- 
tions, while the points at which the sputum meets the 
most resistance during expulsion are the arytenoid 
commissure, the posterior insertion of the cords and 
the inner surfaces of the arytenoid cartilages. 

As a general rule it may be said that infection 
occurs proportionately to the exposed position of the 
parts, but we meet with a striking exception in the case 
of the epiglottis. 

In a total of 3,994 lesions, but 436 occurred upon the 
epiglottis and yet no segment of the larynx is more 



ENDOGENETIC AND EXOGENETIC INFECTION. 53 

exposed to insult by the passing secretions, or more 
prone to destrnction when invaded. 

Several strong objections to accepting this localiza- 
tion as a proof of spntal infection may be advanced : 

Cases of laryngeal tuberculosis are frequently seen 
in which the lung lesion is either quiescent or incipient, 
with little or no sputum and therefore practically no 
chance of contact infection; and conversely, many 
cases of advanced phthisis run their lethal course at- 
tended by colossal secretions rich in bacilli without 
the slightest sign of laryngeal involvement, even when 
local predisposition, points of locus minoris resist en- 
tiae, exist. 

A third objection is noted in the fact that those por- 
tions of the larynx that are covered by squamous epi- 
thelium are especially subject to attack, and yet corre- 
sponding parts of the pharynx, the deep posterior and 
lateral walls, are rarely involved. These immune sec- 
tions are natural reservoirs in which the sputum is 
collected and retained for much longer periods than is 
the case with the larynx, where reflex cough is soon 
called into play to aid in its expulsion.. 

The pharyngeal immunity may possibly be due to 
the fact that it is kept in a state of almost constant ex- 
citation through the passage of food and mucus, and 
that therefore the bacilli find little chance of lodge- 
ment, although at night these disadvantages are re- 
moved and the pharynx is as much at rest as the lower 
segments. 

(2) Arrosion Ulcers. 

The chief support afforded the followers of the exo- 
genetic hypothesis is furnished by the occurrence of 



54 



LARYNGEAL. TUBEBCULOSIS. 



the so-called "arrosion" ulcers, due undoubtedly to 
the action of the secretions upon a normal or abraded 
mucosa, resulting in local necrosis and, as a general 
thing, subsequent infection by the tubercle bacillus. 

The clearest exposition of this view has been given 
by Orth (Lehrbuch der spec. path. Anat.) who writes: 

"When we have to deal with a typical case, where, 
perhaps, there is only a large ulcerated cavity in one 
apex; where all the bronchi through which the secre- 
tions from this cavity must pass during expectoration 
are full of tubercular ulcers; where we find smaller 
ulcers only on that side of the main bronchus and lower 
portion of the trachea, which, from the position of the 
body, must come into contact with the secretion, and 
the ulcers are found to increase in size and frequency 
as we ascend; where, omitting a part of the trachea, 
the tubercular affection is seen to be more extensive 
wherever the walls of the air passages are approxi- 
mated and the sputum is therefore forced against the 
sides, — the conclusion seems inevitable that the spu- 
tum constitutes the vehicle by which the tubercular 
toxin is conveyed from the cavity and deposited during 
its transit through the air passages on favorable re- 
gions of the mucous membranes." 

That infection does occur in this manner must 
be admitted, but as the ulcers resulting from this 
form of infection are relatively rare and essentially 
different both anatomically and clinically from the true 
tuberculous ulcer, which is due to the sloughing of the 
superficial membranes through the pressure of the con- 
stantly increasing subepithelial tubercles, their occur- 
rence cannot militate against the theory of usual in fee- 



ENDOGENETIC AND EXOGENETIC INFECTION. 55 

tiontion from within. The arrosion ulcers are not the 
result of infiltration but are due to the degeneration 
of superficial miliary tubercles. They are always su- 
perficial, have a decided tendency to spread and 
fail to show, upon the floor and about the edges, the 
characteristic granulations of the typical ulcers. 

The base is commonly covered by a thick, yellowish 
exudate that frequently forms a true fibrinous mem- 
brane elevated above the surrounding parts, hence the 
older name of diphtheritic, or aphthous ulcers. 

They are to be looked upon as a specific manifesta- 
tion of the tuberculous process, due to contact infec- 
tion, and while practically always tuberculous, they 
may in occasional instances be purely catarrhal. 

That is, in the larynges of tuberculous patients we 
sometimes meet with small points of necrosis due to 
irritation by the sputum and cough, — the same as we 
sometimes have small corrosion ulcers in the vagina 
or in pure catarrhal laryngitis, — but infection almost 
immediately follows, hence there is small opportunity 
for their observation. 

Against the theory of endogenetic infection it has 
been advanced that if invasion occurred through these 
channels, the entire region supplied by the vessel or 
vessels in fault would be equally exposed to danger, 
instead of isolated parts thereof. Such a conclusion is 
unwarranted; the spots where the sputum impinges 
and those most irritated by cough or physiologic move- 
ments, are necessarily points of lowered resistance, 
and as some previous weakening of the tissue resist- 
ance is essential to the development of tuberculous 
changes, no matter in what way the toxin is conveyed, 



56 LARYNGEAL TUBERCULOSIS. 

it is at these points that infection would follow even 
from a widely distributed lymphatic or hematogenous 
deposit. 

According to Cornet the assumption of a predisposi- 
tion does not help the case, for he claims the 
more favored areas lose their apparent immunity as 
soon as a focus develops in their immediate neighbor- 
hood, so that they then become as liable to invasion and 
as little resistant to destruction when involved, as the 
more predisposed areas. 

Although he denies that local predisposition of the 
larynx exists, he explains the infrequency of pharyn- 
geal infection, in those parts unduly exposed to sputal 
irritation, by the assumption of some inherent property 
of self-defense. 

Auto-infection is occasionally observable, particu- 
larly in the case of ulcers upon the edges of the cords, 
and supports, in very small measure, the theory of spu- 
tal infection. 

As a final argument in favor of lymphatic transmis- 
sion we may advance the infrequency of primary 
laryngeal infection. 

It has been shown that in no case of tuberculous 
laryngitis so far studied has there been proven an ab- 
sence of foci in the glands, even when the lungs were 
entirely free of disease. If infection occurred generally 
by contact, through the bacilli entering the tissues by 
way of gland ducts and intact epithelium, is it not 
reasonable to suppose, in view of the ubiquity of the 
bacillus, that primary laryngeal infection worild be 
more frequently observed? Moreover, the larynx 
offers an exceptionally favorable point of attack. 



ENDOGENETIC AND EXOGENETIC INFECTION. 57 

because in a large percentage of people some catarrhal 
inflammation, leading to points of locus minoris resis- 
tentiae, exists. 

The connection between laryngeal and lymphatic dis- 
ease in some cases has been established, and not alone 
of the cervical glands and tonsils but of the bronchial 
glands as well. 

Careful consideration of all these conflicting theories 
which cannot be fully reconciled, permits of no other 
deduction than that both agencies are at fault, but that 
the more common route of infection is that of the blood 
and lymph vessels, while the role of the sputum is a 
not infrequent but somewhat subsidiary one. 



CHAPTEE IV. 

PREDISPOSING CAUSES. 
FREQUENCY. 



Statistics bearing upon the frequency with which 
laryngeal phthisis occurs in consumptives vary to a 
striking degree : 



Pulmonary Laryngeal 
Cases 



Kruse 742 

Gaul 424 

Eichorst (autopsies) 462 

Heinze (autopsies) 1,226 

De Lamallerie 502 

Willigk Not given 

Buhl 

Krieg 

Frey 

Frommel 

Mackenzie 

Lublinski 

Schaffer 

Lake, Mackenzie & Magenau . . . 1,189 



volvement 


Percentage 


123 


16.6 


113 


25.7 


130 


28.1 


376 


30.6 


222 


44.2 


Not given 


13.8 




15.5 




26.0 




26.1 




40.0 




33.7 




60.0 




97.0 


373 


30.18 



34.54% 



Thus the average of fourteen reports from various 
sections of the world is 34.5 per cent, which may be 
accepted as a fair estimate, although the inclusion of 
incipient cases through the medium of systematic ex- 



PBEDISrOSING CAUSES. 59 

animations of all phthisical subjects, without awaiting 
the development of symptoms referable to the throat, 
would without question materially increase this per- 
centage. A lamentable tendency to neglect routine 
laryngoscopic examinations exists even in many of the 
most up-to-date sanatoria, thus accounting in large 
measure for the popular misconception which regards 
laryngitis as a relatively uncommon complication. 

The lowest percentage recorded is by Maurice Per- 
rin (Rev. foebd. de Laryngologie, d'Otologie, 1902) who 
in 325 cases of pulmonary tuberculosis found but 1.2 
per cent with laryngeal involvement. 

The majority of the sanatoria refuse to admit patients 
with advanced laryngeal lesions and in consequence 
the percentage of these cases, based upon such records, 
is often artificially low. 

Kidd (Albutt's. ''System of Medicine") finds that 
50 per cent of all cases dying of phthisis show, upon 
post-mortem, some tuberculous changes in the larynx. 

AGE. 

The age of the individual exercises a strong determi- 
ning influence, and a study of the statistics shows that 
it is most common between the twentieth and fortieth 
years. 

Moritz Schmidt finds that two-thirds of all the cases 
occur between the ages of twenty and forty. 

Schrotter places the average age at thirty; Kruse 
from twenty to thirty; Jurasz, thirty to forty, and 
Heinze and Mackenzie from twenty to thirty. 

In the author's cases the average has tended toward 
the lower limit of the above period, but some allow- 



60 LAEYNGEAL TUBERCULOSIS. 

ance must be made in considering this series, owing to 
the fact that it includes many cases from the Y. M. C. 
A. Health Farm, where most of the patients are young 
men in the early twenties. 

The tendency of the disease to attack people between 
their twentieth and fortieth years is shown in the 
following analysis of 2,469 cases : 

AUTHORITY • 

Agnes 
Memorial Mae- 
Age Sanatorium kenzie Magenau Lake Author Total 

1-10 * 1 3 2 6 

11-20 6 35 24 100 131 296 

21-30 82 194 139 252 465 1,132 

31-40 33 162 141 165 203 704 

41-50 11 82 67 64 71 295 

51 and upwards.. 1 27 28 21 32 109 

Totals 133 500 400 605 904 2,542 

*Not admitted under 16 years. 

A table by Lake shows how the proportion of con- 
sumptives attacked by tuberculous laryngitis increases 
up to this age period and then steadily declines : 

Pulmonary Laryngeal Percentage of 

Age Phthisis Ulceration Laryngeal Cases 

Under 1 year 13 1 7.7 

1-10 39 4 10.25 

11-20 92 23 25.0 

21-30 406 130 32.0 

31-40 303 112 36.96 

41-50 179 67 37.43 

51-60 104 27 25.96 

61-70 53 9 17.17 

Wide extremes are occasionally met: Santvoord saw 
undoubted tuberculosis in the larynx of a child of 31 
months, Schmidt in one of twelve months, and Rhein- 
dorfT (Ueb. Kehlkopftiibcrcul. i. Kindesalter, i. Anschl. 
a. e. Fall v. Pseudo paralyse u. Tub erculose,, Diss., 
Wurzburg, 1891) a case of combined tuberculosis and 
syphilis in a child of 13 months. 



PREDISPOSING CAUSES. 61 

I have seen one fatal case in a child of sixteen 
months. 

J. Solis Cohen (American Journal of the Medical 
Sciences, January, 1883) reports a case of miliary tu- 
bercles in a child of seven years. 

Heinze places the percentage of laryngeal involve- 
ments occurring in infants at from two to three, and 
Frobelius at from two to four per cent. 

Schech has seen but one case under ten years of age. 
Tuberculous laryngitis in children under ten years is 
clinically rare although it is undoubtedly more com- 
mon than statistics indicate. This is due in large mea- 
sure to the general impracticability of conducting 
thorough laryngoscopic examinations in the very young 
and hence the overlooking of many incipient cases. 

The comparative immunity enjoyed by children may 
be credited in part to the fact that pulmonary consump- 
tion runs a rapid course in the young, and that a fatal 
termination ensues before there is time for, or a likeli- 
hood of general infection, and to the additional safe- 
guard of an absence of preceding laryngeal disease. 

The condition is rarely met with in those of advanced 
age but few cases having been seen after the seven- 
tieth year. The oldest of whom I have record origi- 
nated in the seventy-fourth year. This case recovered. 
Hardie (Laryngoscope, July, 1905) reports a case in a 
man of 76, with ulceration of the epiglottis and poste- 
rior wall. 

SEX. 

The following table shows the relative frequency 
with which the two sexes are affected : 



62 LAKYNGEAL TUBERCULOSIS. 

PROPORTION 
Author No. of Cases Males Females 

Mackenzie 500 2.7 1 

Schmidt 2,156 2.45 1 

Heinze 376 1.5 1 

Kruse 3.7 1 

Jurasz 3.0 1 

Rosenberg 2.4 1 

Lublinski ... 2.3 1 

Magenau 400 2.17 1 

Lake 667 2.44 1 

Bezold 2.62 1 

Phipps Institute 67 2.0 1 

Agnes Memorial Sanatorium 133 1.29 1 

Author 904 1.6 1 

Average 2 . 09 1 

The disparity in the proportion of the two sexes has 
been much less in my series than in the others reported, 
excepting that of the Agnes Memorial Sanatorium, and 
this despite the fact that cases have been inclnded from 
one institution limited to male patients. 

OCCUPATION. 

A direct connection between this greater suscepti- 
bility on the part of the male and the greater aver- 
age unhealthfulness of his surroundings and habits can 
be seen in considering the role of occupations as a 
causative factor. 

The avocations of 1,280 patients with laryngeal tu- 
berculosis are shown in the following table : 

1. Voice users (actors, singers, elocutionists, huck- 

sters, fakirs, etc.) 71 

2. Open air occupations (cabmen, carmen, solicit- 

ors, collectors, etc.) 101 

3. Laborers and porters 64 

4. Clerks, accountants, shop assistants, stenograph- 

ers, etc 196 

5. Painters 32 

6. Students 81 

7. Traveling salesmen 40 

8. Saloon-keepers, etc 21 

9. Artists (painters, photographers, etc.) 14 



PREDISPOSING CAUSES. 63 

10. Housewives (laundresses, servants, etc ) 203 

11. Physicians, dentists and nurses " 58 

12. Dusty occupations (bakers, farriers stone-cut- 

ters, etc.) ' 86 

13. Sedentary occupations (tailors, ' ' shoemakers 

dressmakers, etc.) 72 

14. Machinists, engineers [][[ §% 

15. Merchants, lawyers, bankers, etc . '. . . .... ] [ . .' ... 81 

16. Farmers 49 

17. Musicians — wind instruments ' ' .' 12 

19. No occupations \\' m 37 

1,280 

Lake's table, showing the occupations of 200 patients 
with laryngeal tuberculosis, compared with 200 con- 
secutive cases of phthisis admitted in each of the years 
1898 and 1899 to the Mount Vernon Hospital for Con- 
sumption, follows: 

FIRST 200 CASES 
Laryngeal — In Years — 
Occupation Cases (200) 1898 1S99 

1. Dusty occupations (bakers, far- 

riers, etc 50 55 59 

2. Sedentary occupations (tailors, 

shoemakers, etc 17 21 15 

3. Clerks , 15 6 9 

4. Shop-assistants 12 9 9 

5. W|aiters 8 5 9 

6. Housewives, servants and laun- 

dresses 31 43 51 

7. Voice users (actors, singers, etc.) 7 2 6 

8. Painters 11 12 7 

9. Laborers and porters 26 25 6 

10. Open air occupations (cabmen, 

carmen, etc.) 11 9 18 

11. Healthy occupations 12 13 11 

While those occupations which are particularly un- 
healthful show a large percentage of cases with laryn- 
geal involvement, maintaining a relative correspond- 
ence to the cases of pulmonary phthisis in the same 
occupations, it cannot be shown, despite common belief 
to the contrary, that avocations demanding great vocal 
strain under unhygienic surroundings, i. e., vaudeville 



64 LARYNGEAL TUBERCULOSIS. 

artists, singers, fakirs, etc., show an unusual percent- 
age, at least in excess of that shown by others living 
under the same conditions but not forced to undergo 
particular vocal effort. As practically all singers and 
fakirs of this class suffer from chronic laryngitis it 
would tend to the belief that this condition, so com- 
monly considered a precursor of tuberculosis, can have 
but slight determining effect. 

Living under the unhygienic conditions of the tene- 
ments, etc., does not seem to exert the same deleterious 
influence that it does upon lung infection, for throat in- 
volvements are found as frequently in people from the 
farms and rural communities as from the tenements 
and congested areas of the cities. 

If tuberculous laryngitis occurred as a primary man- 
ifestation of the disease, we would expect to find a 
large proportion of the cases from those avocations en- 
tailing undue exposure to contagion, independent of the 
number of pulmonary cases. 

TOBACCO AND ALCOHOL. 

Tobacco and alcohol can be at fault in favoring in- 
fection only in so far as they are responsible for con- 
stitutional and local lessening of tissue resistance. In 
moderation they exert no appreciable influence, and 
statistics do not show an increased percentage even in 
excessive indulgers. 

PREVIOUS LOCAL DISEASE. 

Some sort of previous disease or abnormal condition 
of the laryngeal tissues affected is common, if not in* 
variably essential. 



PKEDISPOSIN G CAUSES. 65 

Woodhead, in his lecture before the Henry Phipps 
Institute in 1905, said: 

"The bacillus must make it way not merely onto a 
free surface, but into the tissues of the body, before it 
can do any harm ; nay, more, it seems that, in the hu- 
man body at any rate, the tissues must be damaged or 
weakened and a special mode of entrance into these 
damaged tissues must be prepared for the tubercle 
bacillus before it can work its dire effects. 

"From my experiments on animals I am satisfied, 
as are all experimenters, that tuberculosis is never pro- 
duced without the presence of the tubercle bacillus, but 
unless the tissues are weakened or dam- 
aged, i. e., the soil is prepared, there can be no reaction 
between the bacillus and the tissues which can end in 
the production of a tuberculous lesion." 

One of the most frequent of these causes of impaired 
resistance is syphillis. An active lesion is not essen- 
tial although the secondary infection of such by the 
tubercle bacillus is frequently observed, but old lesions 
presumably cured may be as pernicious as the more 
recent, in that the parts are so weakened as to be sus- 
ceptible to insults normally impotent. 

ACUTE LARYNGITIS. 

Acute laryngitis in the phthisical rarely induces the 
accession of local tuberculosis if the attack be promptly 
combatted, but neglected attacks or frequent seizures 
may, under fortuitous conditions, lead to infection or, 
in healed lesions, to a recurrence. 

CHRONIC LARYNGITIS. 

In a considerable percentage of cases of laryngeal 



66 LAEYNGEAL TUBEKCULOSIS. 

phthisis chronic laryngitis exists to a certain degree, 
independent of, or in connection with pharyngitis and 
obstrnctive lesions of the nose. How much influence 
this chronic inflammation has npon the subsequent 
development of laryngeal tuberculosis it is impossible 
to say. 

Personally, I have been unable to establish any direct 
etiologic relationship and, as considered in the dis- 
cussion of occupations, it is impossible to show that 
those avocations leading to chronic catarrh show an 
unduly large proportion of cases of laryngeal phthisis. 

NATIONALITY. 

All races show an almost equal susceptibility. It 
has been claimed by some observers, i. e., Norman 
Bridge (Tuberculosis, p. 75, 1903) that: "Nationality 
has some influence on susceptibility in tuberculosis. 
The Jewish people have very little of it." 

The fallacy of this is readily shown. Of the last 100 
cases occurring in the author's practice, 24 were Jews, 
practically 25 per cent, and these did not include cases 
resident in the National Jewish Hospital for Consump- 
tives, or the Jewish Consumptives ' Eelief Society, 
where there are at all times from fifteen to forty laryn- 
geal cases in a total of some one hundred and fifty 
patients. 

PHYSICAL CHARACTERISTICS. 

Certain peculiarities of physique and temperament 
have been advanced as likely causes of predisposition, 
but as yet they are little more than theoretical conjec- 
tures. 



PKEDISPOSING CAUSES. 67 

Thost claims to have observed a greater suscepti- 
bility on the part of individuals of a tall, slender habit, 
with long throats and deep voices. I have been unable 
to find any verification of this. 

PREGNANCY. 

Child-bearing in consumptives may be the cause of a 
tuberculous invasion of the larynx through a lighting 
up of the general process with disseminated infections, 
or it may lead to the rapid progression of an already 
existent focus. The strong influence of the parturient 
state will be seen in the discussion of prognosis. 

In conclusion it may be stated as axiomatic that any 
condition either local or constitutional, leading to im- 
paired vitality of the larynx, renders it more suscept- 
ible to invasion by the tubercle bacillus and less resist- 
ant to attack when invaded. 



CHAPTER V. 
PATHOLOGY. 



Two groups of phenomena, general and local, follow 
the advent of tubercle bacilli into the tissues. 

The general manifestations, fever, tissue waste, etc., 
due to the absorption of soluble proteins, belong to the 
domain of general tuberculosis rather than to a study 
of the disease as manifest in the larynx. 

The local effects are likewise of a dual nature; those 
consequent upon the action of the bacillus as a simple 
corpus alienum, and those dependent upon its metabolic 
products and its proteins. As a corpus alienum, the 
bacillus produces changes of a purely inflammatory na- 
ture, in large measure of a productive type. The pro- 
teins and metabolic products, on the other hand, are 
responsible for the exudative processes, but in practice 
it is impossible to differentiate these actions or agen- 
cies in considering the tissue changes, for their action 
is concurrent. 

The primary deposit of the bacilli in the larynx, no 
matter through what channel they may have passed 
(intact epithelium, erosions, gland ducts, blood or lym- 
phatic vessels) occurs in the sub-epithelial layers of the 
mucosa and in the sub-nmcosa and here their first 



PATHOLOGY. 69 

effects are produced, usually about the blood vessels 
and glandular acini. 

One of four forms of the disease may be provoked : 
infiltration, ulceration, tuberculoma, or miliary 
tubercle. 

Of these the infiltration and tuberculoma may exist 
as isolated processes, but the ulcer and miliary tubercle 
are always preceded and accompanied by other tuber- 
culous conditions. 

The Infiltrate : — Pathological and anatomical inves- 
tigations, as well as clinical observation, establish the 
fact that every typical tuberculous infection of the 
larynx begins as an infiltration. Clinically the picture 
varies with the anatomic peculiarities of the parts in- 
volved as well as with the extent of the process, the 
degree of swelling depending upon the thickness of 
the submucosa and its relations to the deeper laryngeal 
structures. In the aryepiglottidean folds, the interary- 
tenoid sulcus and upon the arytenoid cartilages the 
infiltrate may attain large proportions; on the vocal 
cords, the lingual surface of the epiglottis and 
the inner surface of the arytenoids, where there 
is a scantier supply of submucous tissue, the swelling 
is usually of moderate extent. The ventricular bands 
occupy a medium position; the enlargement as a rule 
is slight, although it may occasionally be sufficient to 
produce perfect approximation. 

Perichondritis is especially liable to occur in those 
localities where the mucosa is closely adherent to the 
cartilage, i. e., the epiglottis and arytenoids. 

Microscopically an infiltrated area shows the follow- 
ing structure : A normal epithelium, unless the process 



70 LARYNGEAL TUBERCULOSIS. 

has advanced to the stage of ulceration or at those 
points beneath which there is a large aggregation of 
tubercles, and a subepithelial stratum thickened 
from two to four times the normal diameter by a de- 
posit of small mononuclear cells, each with a deeply 
staining nucleus and small protoplasmic body. The 
primary deposit of these cells usually takes place im- 
mediately above the glands, and they are embedded in 




Fig. 1. 



a fine or coarse network of connective tissue. Enclosed 
in this mass there are usually found numerous small 
and large nodules, or tubercles, the units of which this 
infiltrated mass is composed. (Fig. 1.) 

The Tubercle: As visible macroscopically, the tuber- 
cle is a translucent, pearl or grayish colored, spherical 
body, composed of a cluster of microscopic nodules, the 



PATHOLOGY. 71 

whole forming a body that ranges in size from a mus- 
tard seed to a pea. Caseation destroys the translu- 
cent appearance and it then becomes opaque and yellow, 
or a dirty white in color. 

The first step in the formation of a tubercle is a 
proliferation of the endothelial cells of a blood vessel or 
lymphatic, from which there results a mass of epi- 
thelioid cells, so-called because of their resemblance to 
epithelial cells. 

Interspersed among these epithelioid cells are a num- 
ber of lymphoid cells, separated and enclosed by a 
sparse fibrillae. The formation within this mass of 
one or more giant cells completes the typical tubercle, — 
a rounded nodule, circumscribed and bloodless. 

The tubercle formation is most marked in the super- 
ficial layers of the mucous membranes, immediately be- 
neath and parallel with the epithelial layer; rarely it 
extends with even distribution throughout the entire 
thickness of the mucosa. 

In many instances there exists between the epithelial 
border and the superficial deposit of tubercles a zone 
of uninvaded tissue, rich in capillaries and containing 
a few round cells. It was this appearance that led 
Heinze and Korkunotf to the assumption that the ba- 
cilli must be deposited from within by way of the lym- 
phatic and blood vessels. 

The Giant Cell : — The giant cell is situated within the 
tubercle, and is often separated from the small round 
cells by a collection of large, nucleated, epithelioid cells. 
These small cells, in gradually decreasing numbers, in- 
filtrate both toward the interior and exterior. 

The giant cell itself, a globular body, is composed of 



72 



LARYNGEAL TUBERCULOSIS. 



a central mass of granular protoplasm showing some 
degeneration, and a number of nuclei arranged in a 
semi-lunar, circular or irregular form around the peri- 
phery but probably never in the center. The cell or 
cells — there may be one or several — occupy either the 
center or periphery of the tubercle. (Fig. 2.) 




Fig. 2 



The giant cell is frequently found in conditions not 
tuberculous, i. e., many of the other infectious granu- 
lomata, in sarcomata, and in areas chronically irritated 
by foreign bodies. 

In the tubercle they may be very numerous or en- 
tirely absent. 

The number of tubercles likewise varies, depending 



PATHOLOGY. 7 



o 



in large measure upon the tissue involved, and hence 
their absence, together with that of the giant cells, can- 
not entirely disprove the diagnosis of tuberculosis. 

For the same reason the presence of the giant cells 
alone cannot be taken as an absolute sign of tubercu- 
losis. 

Within the tubercle no blood vessels are seen; for a 
brief period they persist in the tissues between the 
individual tubercles but even here they soon disappear. 

At this stage of development the tubercle commonly 
undergoes one of two changes — degeneration or organi- 
zation. 

The center of the tubercle begins to show the same 
condition that has been noted as occurring in the 
center of the giant cell : the increase in size of the indi- 
vidual tubercle and the conglomeration of the various 
neighboring tubercles result in shutting off nutrition 
from the center of the mass, with its consequent de- 
struction, or caseous degeneration. 

To this effect the toxic properties of the bacilli con- 
tribute. In the course of time this cheesy material 
liquifies, extends to the surface, breaks through the 
superficial layers and forms an ulcer. In the lungs this 
fluid material, after undergoing certain chemical 
changes, may unite with the lime salts that are dis- 
solved in the blood and are present in the liquid mass, 
and form calcareous deposits. In the larynx, however, 
this calcareous degeneration has never been observed. 
Organization, or fibrous transformation, however, is 
not rare, and is the method by which the process be- 
comes circumscribed. The areas involved are slowly 
converted into scar tissue, i. e., fibrous transformation, 



74 LARYNGEAL TUBERCULOSIS. 

with encapsulation of the bacilli. If the bacilli are de- 
stroyed the disease is cured, otherwise the word arrest 
is to be employed. 

So long as these encapsulated areas, enclosing living 
bacilli, remain intact, the condition continues quiescent, 
but subsequent traumatism, through whatever media, 
may lead to destruction of the protecting wall with 
breaking down of the old foci or invasion of new 
areas. 

Ee-attacks are, therefore, as a rule more severe and 
harder to combat than the primary. 

The Bacilli : — The bacilli in their distribution usually 
correspond closely to the arrangement of the infiltrated 
tissues ; they are numerous in the deeper layers, more 
sparsely distributed as the superficial layers are 
reached and usually entirely absent in the epithelial 
layer. In the early stage of tubercle evolution the 
bacilli lie between the epithelioid cells and in the tis- 
sues, but later they are situated to a large extent within 
the cells and especially within the giant cells. 

In sections of involved tissue removed endolaryn- 
geally, the bacilli are difficult to demonstrate and rarely 
more than one or two are to be found even upon pro- 
longed research. 

The Ulcer: — The transformation of an infiltrate into 
an ulcer is due to the caseation of one or more subepi- 
thelial tubercles. The tubercles from their primary 
localization in the submucous tissues extend gradually 
toward the surface until the epithelial layer is com- 
pletely detached and destroyed, and the ulcer thus 
formed enlarges through a continuation of the degener- 



PATHOLOGY. 



iO 



ative process in the individual tubercles, and the coa- 
lescense of neighboring ones. (Fig. 3.) 

The nature and extent of the individual ulcer de- 
pend upon the character and location of the preceeding 
infiltration. In the beginning it is always superficial 
unless it has its origin in an infiltrate that involves the 
glands or glandular layer, in which case it forms a 
crater-shaped depression with prominent edges, and 







"■**, 






• -•■ oStJ f • 



Fig. 3. 



may extend to and involve the perichondrium and carti- 
lage. 

The variety not situated immediately above the gland- 
ular layer is superficial and extends very slowly toward 
the deeper structures; it has an indefinite border line, 
irregular, flat or but slightly elevated, and its base is 
covered by a yellowish exudate through which appear 
numerous small granulations. If the infiltrate has been 



76 LARYNGEAL TUBERCULOSIS. 

extensive the resultant nicer is generally large and shal- 
low, but if the original deposit was circumscribed and 
minute, the ulcer is a mere pinhead spot of necrosis. 

In all forms of the tuberculous ulcer resulting from 
infiltration there is present as a typical feature the 
granulations which cover the base and surround the 
edges. Occasionally these become exuberant to a de- 
gree sufficient to closely resemble papillomata, and 
almost completely hide the ulcer and fill the glottis. 

The "arrosion" or contact ulcers have different char- 
acteristics. They are always flat and superficial; they 
spread rapidly along the surface of the mucosa and 
have little if any granulation tissue, a marked charac- 
teristic of the true ulcer. The exudate which covers 
the base is thick, tenacious, yellow in color, and some- 
times slightly elevated above the level of the surround- 
ing parts. 

Taberculomata: — The tuberculous tumor is one of 
the rarest manifestations of the disease, but it is impos- 
sible to estimate its comparative frequency owing to the 
fact that there is as yet no strict understanding as to 
the type of cases to which the term tumor should be 
applied. 

The most satisfactory interpretation of the term is 
that of Schech (Handbuch der Laryngologie und Rh'ui- 
ologie, p. 1144), who understands it to include all tuber- 
culous growths resembling true tumors where the pre- 
vious existence of an ulcer upon the affected spot can 
be definitely excluded. 

Such growth are most commonly situated upon the 
posterior wall, in the ventriculns Morgagni and at the 
anterior commissure. In rarer instances they occur 



PATHOLOGY. 7 / 

upon the vocal cords the epiglottis and the ventricular 
bands. 

In size they vary from a pin's head to a hickory nut, 
and may appear singly or in clusters. 

Microscopically the tumor is composed of a number 
of nodules covered by a thickened pavement epithelium. 

The individual tubercles consist of numerous small 
round cells, giant cells and bacilli, and usually show 
some evidence of caseous degeneration. 

The Miliary Tubercle : — The miliary tubercle is 
rarely seen macro scopically in the larynx, but that the 
condition does occasionally occur and is clinically rec- 
ognizable can no longer be denied. Many cases so 
classed, however, are nothing more than minute granu- 
lations, obstructed gland ducts or epithelial abscesses. 

The miliary tubercle soon breaks down and ulcerates, 
but in its early stages it may be seen as an exceedingly 
minute, gray, yellow or whitish spot gathered in clus- 
ters over an infiltrated area or upon the base and 
around the edges of an ulcer. 

The Glands : — Two forms of glandular tuberculosis 
are recognized: the inter and intra-acinous. In the 
former there is a multiplication of cells in the connec- 
tive tissue occupying the spaces between the individual 
acini, causing their separation and compression, where- 
by the normal contour is completely destroyed. 

The intra-acinous involvement is characterized by 
a deposit of cells in the acini themselves, ending in 
complete obliteration. 

The Blood Vessels : — Cross section of the blood-ves- 
sels shows a pronounced zone of small round cells about 
the vessels, mostly outside the adventitia but also, to a 



78 LARYNGEAL TUBERCULOSIS. 

small extent, invading it, causing an increase of the 
connective tissue. 

Unless the vessel is fully enclosed by a tubercle the 
muscular layer remains intact even when the adven- 
titia has been destroyed. 

Muscles : — Tubercles seldom invade the muscles but 
that this invasion does exceptionally occur has been 
demonstrated by Heinze, and Schech has shown their 
presence in the crico-arytenoideus posticus muscle in a 
case of tuberculous perichondritis of the cricoid carti- 
lage. 

Atrophy of the muscles with fatty and waxy degen- 
eration, due to systemic infection, may occur and pro- 
duce paralysis. 

As will be shown later this condition is sometimes 
accountable for aphonia in cases of pulmonary phthisis 
when the larynx is apparently free of disease. 

Nerves : — Neuritis and proliferation of the nerve 
filaments have been described by Dansac (Annales des 
Maladies de VOreille, December, 1893). To this condi- 
tion Gouguenheim gave the name "tubercular 
pseudoneuroma. ' ' 

A paralysis is not infrequently seen that may be 
traced to pressure upon the recurrent laryngeal nerve 
by enlarged bronchial glands, or in some instances, to 
the nerve being embedded in an adherent pleura at the 
apex. 

The Mucosa : — Congestion or anemia of the mucous 
membrane unaccompanied by other evidences of local 
disease, and frequently classed as tuberculous or pre- 
tuberculous catarrh or anemia, cannot with any his- 
tologic warrant, be so considered. They are to be 



PATHOLOGY. 79 

classed as "catarrh" or "anemia" accompanying tu- 
berculosis. 

With the advance of infiltration the epithelium be- 
comes detached and finally ulcerates, but it remains un- 
affected in the initial stages, except in the case of ar- 
rosion ulcers where superficial necrosis is the primary 
change. 

Chondritis and Perichondritis : — Chondritis, neces- 
sarily associated with perichondritis, is a late mani- 
festation developing only when the tuberculous disease 
has extended to or in the immediate vicinity of the peri- 
chondrium. 

The cartilages of the larynx are not involved with 
equal frequency : those most often affected are the ary- 
tenoids; then in the order of frequency come the epi- 
glottis, the cricoid and the thyroid. The thyroid, howev- 
er, according to many observers, is most frequently in- 
volved "primarily," — that is, without demonstrable 
disease elsewhere. 

Mixed Infection: — In the ulcerations other bacteria 
are usually found, notably the Streptococci and Staphy- 
lococci, consequently most ulcers can be considered as 
depending upon mixed infection. The tubercle bacillus 
is the first cause, however, and is found in the deeper 
structures, while the Strepto- and Staphylococci are 
near or upon the surface. 



CHAPTER VI. 
SUBJECTIVE SYMPTOMS. 



Laryngeal phthisis is accompanied by symptoms so 
complex that a thoroughly comprehensive view can be 
obtained only by some such arbitrary classification as 
the following : 

(A.) Subjective symptoms. 

(B.) Objective symptoms. 

The subjective phenomena are subdivided into two 
groups : 

(C.) Symptoms peculiar to the lungs. 

(D.) Symptoms peculiar to the larynx, and those 
common to the lungs and larynx. 

The manifestations falling in the latter group (D.) 
are best considered under two heads : 

(1.) Symptoms due to systemic poisoning unas- 
sociated with local structural changes of a tuberculous 
nature. 

(2.) Symptoms dependent upon tuberculous cell 
proliferation in the laryngeal tissues. 

(C.) Symptoms peculiar to the lungs: 

Except in rare instances the laryngeal symptoms are 
antedated for variable periods by those dependent 
upon the lungs, and these do not immediately follow 



SUBJECTIVE SYMPTOMS. 81 

infection; — a sufficient time must elapse in which the 
bacilli can produce the changes recognized as typical, 
and this original focus must either produce others or 
disintegrate with diffusion and absorption of the solu- 
ble proteins before constitutional symptoms can ap- 
pear. 

Unfortunately the nature of the process thus pre- 
cludes the appearance of any distinctive signs until 
the disease has become fairly well established. 

The primary symptoms are usually those of lowered 
vitality, evidenced by anemia, dyspepsia, loss of 
weight, appetite, strength, &c. Following — or in some 
cases primarily — there is cough, with or without ex- 
pectoration; fever, usually in the afternoon or even- 
ing with normal morning remissions ; huskiness of the 
voice or simple voice fatigue; night sweats; hemor- 
rhage ; pleuritic pains, &c. 

(D.) Symptoms peculiar to the larynx and those 
common to the lungs and larynx. 

(1.) Phenomena not dependent upon structural 
changes in the larynx: 

Certain alterations in the voice, ranging from simple 
fatigue after prolonged use to complete and lasting 
aphonia, are occasional symptoms of pulmonary tuber- 
culosis unaccompanied by recognizable laryngeal le- 
sions. 

Amblyphonia, or voice weaknesses the most frequent 
of these phenomena and is usually evidenced by a 
sense of laryngeal discomfort or fatigue after pro- 
longed reading or speaking. It is an expression of 
muscular weakness due to anemia or of a lessened 



82 LARYNGEAL TUBERCULOSIS. 

expiratory power consequent upon the gradual elimina- 
tion of certain pulmonary segments. 

This last factor naturally becomes more pronounced 
in the late stages of the disease. The first and more 
important factor — muscular weakness — is active in any 
disease accompanied by rapid or pronounced exhaus- 
tion and is therefore not typical of tuberculosis. 

Voice fatigue may give way to hoarseness and this 
in turn be succeeded by aphonia, although there is no 
regular sequence such as that which usually obtains in 
true tuberculous laryngitis, for either the aphonia or 
hoarseness may be primary without any preceding 
changes. On the other hand the voice may retain its 
original strength and purity throughout the entire 
course of the disease, or in case of preceding altera- 
tions, may return to its normal state shortly before 
death. 

Either aphonia or amblyphonia may precede all 
other symptoms of the disease and thus direct atten- 
tion to the constitutional condition, although they usu- 
ally develop after the pulmonary process has become 
well established. 

In addition to the etiologic factors already men- 
tioned, muscular weakness and expiratory insufficiency, 
two other conditions must be taken into consideration : 
intralaryngeal changes of a non-tuberculous character 
and tuberculosis of contiguous or extralaryngeal 
structures. 

First among these causes is paralysis of the recur- 
rent laryngeal nerve, which by reason of its long 
course and varied relationships is especially subject 
to insult. 



SUBJECTIVE SYMPTOMS. 83 

In considering the etiology it was shown that involve- 
ment of the bronchial glands occurs in nearly all cases 
of pulmonary phthisis and that in a considerable per- 
centage of all cases they are primarily affected. 

Paralysis is frequently due to the pressure of these 
nodules, or to like action upon the part of the tracheal 
glands which are situated along the course of the nerve 
between the trachea and esophagus. 

Pleuritic exudates and adhesions may likewise embed 
the nerves on either side. 

Landgraf, Dansac (Annates des Maladies de 
I 'Oreille, Dec, 1893) and others have described inflam- 
matory processes in the nerves with proliferation of 
the nerve filaments which result in paralysis. — the so- 
called "tubercular pseudo neuroma" of Gouguenheim. 

Dansac has found the condition in arytenoid swell- 
ings, and Landgraf noted a left recurrent paralysis in 
which post-mortem examination showed fatty degen- 
eration of both posterior crico-arytenoids, with de- 
struction of the medullary sheath and axis-cylinders of 
the left nerve. 

Although there was a small enlarged gland pressing 
upon the nerve under the arch of the aorta, he believed 
the degeneration to be the result of primary inflamma- 
tion of the neurilemma rather than of pressure. 

Atrophy of the laryngeal muscles with fatty or waxy 
degeneration, either isolated or in common with like 
changes in the muscles of other organs, has been de- 
scribed by E. Frankel (Lehrbuch d. path, gewebelehre,' 
4th edit.) and may be accountable for certain 
cases of hoarseness. As previously shown, this de- 



84 LARYNGEAL TUBERCULOSIS. 

generation is due to the systemic condition and not 
to local tuberculous infection. 

In nearly all cases of pulmonary phthisis there is 
more or less inflammation of the vocal cords caused by 
coughing and the constant passage of irritant sputum, 
with the formation of mucus threads stretching across 
the glottis from cord to cord, forming a mechanical 
hindrance to pure tone production and leading to 
slight, and usually intermittent, attacks of coughing 
and hoarseness. 

A rarer cause is the former occurence of bleeding or 
pleuritic attacks, leading to voluntary suppression 
through fear of pain or recurring hemorrhage. 

In addition to these manifestations certain other 
symptoms classed as paresthesias, may develop either 
concurrent with, or independent of the vocal phe- 
nomena. 

These sensations, notably those of retained foreign 
bodies, scratching, tickling and excessive dryness, are 
referred to either the larynx or pharynx and are prac- 
tically always provocative of spasmodic attacks of an 
explosive, or shallow, hacking cough, usually dry but 
occasionally accompanied by a small amount of frothy 
mucus. They are an expression of nerve perversion 
and lowered vitality. 

These symptoms, unaccompanied by local tubercu- 
lous disease, may disappear spontaneously or by rea- 
son of treatment, but usually persist and merge in- 
sensibly into the more obstinate symptoms originating 
in specific cell proliferation. The change is so gradual 
that it is usually impossible to determine the exact time 
of transition. 



SUBJECTIVE SYMPTOMS. 85 

' (2.) Symptoms due to specific cell proliferation in 
the laryngeal tissues : 

The advent of a true tuberculous infection is usually 
soon followed by one or more of a group of symptoms 
regarded as more or less characteristic, although cases 
are occasionally seen which progress to death without 
any momentous subjective manifestations. 

The character of the individual symptoms depends 
more upon the locale of the lesion than upon its type 
and extent. 

For example, in many cases of advanced and wide- 
spread extrinsic involvement the purity of tone re- 
mains almost unimpaired throughout the entire course 
of the disease, while on the other hand, moderate in- 
filtration of the inter arytenoid sulcus or arytenoid 
cartilages may lead to complete aphonia. Likewise 
with dysphagia : a small, shallow ulcer of the epiglottis 
or aryteno-epiglottidean folds sometimes produces se- 
vere and lasting pain, and yet widespread ulceration 
and infiltration of the vocal cords, interarytenoid sul- 
cus or ventricular bands rarely causes any dysphagia 
whatsoever. As a general rule it may be said that ex- 
trinsic lesions produce pain and that intrinsic involve- 
ment causes disturbances of phonation. 

VOICE ALTEBATIONS : 

The hoarseness of tuberculosis is produced by condi- 
tions as manifold as the variations in the voice itself. 

The typical tuberculous voice is weak, dull, muffled 
and inflexible, progressing gradually to complete 
aphonia. 

Usuallv it is less harsh and forcible than the raucous 



86 LARYNGEAL TUBERCULOSIS. 

voice of syphilis, although at times it is impossible to 
distinguish between the two, for either may depart 
from the typical and assume the characteristics of the 
other. It is invariably produced by gross lesions of the 
cords, infiltrations and ulcerations producing an un- 
even edge; by inter-arytenoidal swellings, enlarged 
arytenoids, ankylosis of the crico-arytenoidal joints 
and extensive infiltrations of the ventricular bands. 

Small nodal thickenings on the cords frequently lead 
to the condition known as diplophonia : a voice gen- 
erally normal but occasionally broken by sudden 
changes in pitch. The same condition is met in syphil- 
itic laryngitis and in certain small tumor-like growths, 
i. e., singers' nodules, polypi, &c. 

Moderate infiltration of the cords unaccompanied by 
ulceration, and lesions leading to imperfect adduction, 
produce as a rule nothing more serious than slight muf- 
fling and premature fatigue. 

Large infiltrations of the ventricular bands interfere 
with tone production to as great an extent as involve- 
ment of the true cords. 

It is needless to explain why absolutely no inference 
can be drawn as to the extent or nature of the local 
lesions from the condition of the voice, although this is 
a common error of the medical profession as well as of 
the laity. 

In like manner we cannot conclude during the course 
of treatment, that because of progressive voice destruc- 
tion, the process is advancing, nor, per contra, because 
of a gradual improvement in phonation that the condi- 
tion is nearing arrest or undergoing gradual better- 
ment. 



SUBJECTIVE SYMPTOMS. 87 

Complete cure may result with permanent hoarse- 
ness due to a distorted cord, or with a lasting aphonia 
consequent upon ankylosis or recurrent paralysis; on 
the other hand, the voice may be regained while lesions 
of other segments of the larynx, i. e., extrinsic, prog- 
ress and disintegrate. 

Occasionally an atypical case is met, in which there 
is aphonia with lesions presumably exerting no direct 
influence upon tone production, and in which the modus 
operandi cannot be satisfactorily explained. 

Cough : — Cough practically always accompanies tu- 
berculous laryngeal disease but some few cases escape 
any except that essential to the removal of sputum. In 
the early stages it is usually dry, hacking and of a 
paroxysmal and explosive type; with the advance of 
the infection it becomes looser and easier though more 
frequent. 

If ulcers are present, particularly of the epiglottis, 
either isolated or in combination with disease of the 
aryteno-epigiottidean folds, or if the posterior wall is 
widely infiltrated, each seizure is attended by severe 
pain causing efforts at suppression with consequent 
muffling. 

In any given case, no matter what the type of the 
lesion, it is impossible to form a just estimate as to the 
exact role played by the larynx for many elements con- 
tribute to the production of the phthisical cough. 

Naturally it is in large measure due to the lungs — 
and in so far as the expulsion of secretions is con- 
cerned, necessary. 

Consideration must likewise be given to such causes 
as the dropping of saliva or particles of food into the 



88 LARYNGEAL TUBERCULOSIS. 

larynx, naso-pharyngeal or pharyngeal catarrh, simple 
laryngitis and pressure of the vagus. 

The "nasal," "stomach," and "nervous" coughs 
must also be taken into account. The nervous type of 
cough in particular plays a very important role in these 
cases. 

Granting the importance of these agencies we must 
still recognize the larynx itself as a not inconsiderable 
contributory factor. 

Certain segments, especially the inter-arytenoid 
sulcus, are highly sensitive and when diseased respond 
by outbursts of coughing to the slightest irritation. In 
phthisis this stimulation is given by previous attacks 
of coughing and the frequent passage of irritant secre- 
tions. 

Hypertrophy of the lingual glands, causing contact 
with the epiglottis, is a not uncommon cause of uncon- 
trollable coughing in many cases. These glands are 
enlarged to some extent in almost all old cases of pul- 
monary tuberculosis and in a considerable percentage 
they are themselves the seat of tuberculous changes. 

In this hypersensitive condition of the mucosa many 
things normally impotent become active irritants, i. e., 
inhalation of smoke and dust; immoderate use of the 
voice in speaking, singing or crying; sudden variations 
in temperature; cold air; strong winds; alcohol; to- 
bacco, &c. 

When granulations, irregular growths, rugous infil- 
trations or ulcers exist, the secretions cling tenaciously 
to their uneven surfaces and lead frequently to pro- 
longed attacks of coughing, so severe as to leave the 
patient completely exhausted and fighting for breath. 



SUBJECTIVE SYMPTOMS. 89 

SECRETIONS. 

In the late stages of the disease the lungs pour into 
the already diseased larynx such colossal quantities of 
irritant secretions that the cough becomes almost inces- 
sant and adds much to the already intolerable condi- 
tions. The inflamed laryngeal mucosa itself excretes 
considerable mucus, but not sufficient to occasion any 
particular distress in its expulsion unless there is si- 
multaneous discharge from the lungs. 

With widespread ulceration there is produced a thin, 
dirty white, and occasionally bloody pus, mixed with 
mucus and dead epithelial cells, which has a peculiarly 
sour, penetrative odor. 

In cases of perichondrial abscesses the breath is foul 
and small fragments of cartilage may be found in the 
secretions. 

Small hemorrhages from ulcerated areas or exuber- 
ant granulations are sometimes noted but true bleed- 
ing almost never occurs from the larynx. I have seen 
but one such case, a young man with deep ulceration 
of the right ventricular band from which bleeding oc- 
curred on two separate occasions, the quantity each 
time amounting to between two and three drams. 
After thorough cleansing the blood could be seen exud- 
ing from the ulcerated area. 



'» 



FEVER. 

Laryngeal tuberculosis may cause considerable fever 
at times, as is shown by an increase of the daily range 
coincident with the breaking down of new areas or ex- 
tension of old lesions. 

A temperature of 100 to 101 degrees occasionally ac- 



90 LAHYNGEAL TUBEKCULOSIS. 

companies acute cases where the pulmonary process 
has been for some time quiescent, but as a rule, unless 
the local process is associated with considerable acute 
inflammation, a comparatively rare condition, the tem- 
perature is not much affected by the laryngeal in- 
vasion. After endolaryngeal operations the tempera- 
ture rises from one to three degrees, then gradually re- 
cedes until it is again normal by the end of two or 
three, or occasionally four days. 

DYSPHAGIA. 

True dysphagia occurs, as a rule, only when the 
laryngeal condition is well advanced. 

In 904 personally observed cases of laryngeal phthi- 
sis, dysphagia occurred at some period of the disease 
in 247, or 27.32 per cent. 

The term dysphagia, as here used, includes all varie- 
ties — odynophagia or painful deglutition; dysphagia 
or obstructed swallowing, and the entrance of food and 
liquids into the larynx. 

The conditions practically always coexist and in 
large measure depend upon like pathologic conditions, 
hence the propriety of considering them under the com- 
mon appellation of dysphagia. 

The appearance of this symptom must always be 
considered ominous, both because it marks an extension 
of the process with probable involvement of the deeper, 
or more vulnerable structures, and because, unless 
promptly controlled, the consequent enforced reduction 
or withdrawal of food leads to rapid collapse. 

Dysphagia is an invariable consequence of all wide- 
spread involvements of the upper aperture of the 



SUBJECTIVE SYMPTOMS. 91 

larynx, i. e., epiglottis and aryteno-epigiottidean folds. 

Moderate infiltrations, or small-sized ulcerations of 
the epiglottis and aryteno-epigiottidean folds may be 
unaccompanied by pain, but when either process is 
moderately advanced each act of swallowing is accom- 
plished at the expense of such excruciating and unbear- 
able suffering that starvation seems the lesser evil. 

Extensive infiltrations of the posterior wall or aryte- 
noid cartilages, and perichondritis or perichondrial 
abscesses, are almost as potent in the production of 
pain. In all such cases the passage of liquids is usually 
more difficult than the swallowing of solid and semi- 
liquid food. 

Involvements of the middle larynx, whether ulcera- 
tive or infiltrative, cause pain only in exceptional cases. 
Chordal lesions do not produce dysphagia and the ven- 
tricular bands are responsible only when the lesion is 
acute or widespread. Acute, lancinating pain nearly 
always characterizes the outbreak of miliary tubercles. 

In addition to the painful and difficult deglutition, 
there is frequently added a sharp, neuralgic-like pain 
in the ear of the corresponding side or in both ears in 
bilateral lesions, by transference through the auricular 
branch of the vagus. This aural pain occurs, at some 
period, in practically all dysphagic cases. 

In rarer instances the pain is referred to the sal- 
pingopharyngeal fold and palate. 

Eigidity of the muscles, particularly of the posterior 
wall and epiglottis, leading to imperfect closure during 
deglutition, permits both solids and liquids to enter the 
larynx with violent cough and laryngeal spasm. 

Actual destruction of tissue plays no role in this for 



92 LARYNGEAL TUBERCULOSIS. 

deglutition can occur normally after complete removal 
or destruction of the epiglottis. 

The pain depends upon various causes : — when ul- 
cers exist it is due to the mechanical, thermic and 
chemical action of the passing food and secretions upon 
the exposed nerve endings, but in the absence of ulcera- 
tion it may be ascribed to rigidity, to pressure of the 
inflamed tissues and muscles, to neuritis and to peri- 
chondritis. 

Pain may likewise be caused by speaking or 
coughing through the movement produced in the af- 
fected tissues. Many patients also complain of a con- 
stant ache or soreness in the throat independent of any 
muscular action. 

Intimately associated with the various types of dys- 
phagia is a symptom almost totally overlooked in works 
on laryngeal phthisis, yet it is one that is responsible 
for extreme discomfort and annoyance : the regurgi- 
tation of fluid and solid food through the nose. 

In 247 cases of dysphagia, regurgitation occurred at 
some period of the disease in 198, over 80 per cent. 

Even when the pain is not severe, this factor if pro- 
nounced may necessitate, for the time being, the almost 
complete withdrawal of food. 

DYSPNEA. 

Shortness of breath is the rule in advanced cases of 
phthisis, but true dyspnea of a degree sufficient to 
occasion alarm, dependent upon intralaryngeal swell- 
ing, is the most uncommon of the special symptoms, 
and usually occurs only in those cases where treatment 
has been neglected or where an acute inflammation lias 
been superadded to the chronic process. 



SUBJECTIVE SYMPTOMS. 93 

In any case sndden dyspnea may result, due to 
edema, abscess formation, perichondritis or paraly- 
sis of the abductors. 

The last cause is well exemplified by the following 
case: 

Miss S., aet 29, nurse, was first seen in April, 1904, 
when the larynx presented the following picture : both 
cords extensively ulcerated and infiltrated; ventricu- 
lar bands partially overlap the cords and are deeply 
ulcerated; right arytenoid edematous with a small 
ulcer on its inner surface. 

During the following nine months the condition 
rapidly improved and by January, 1905, there re- 
mained only moderate infiltration of the cords with 
fixation of the right cord in the median line. At this 
time she had an attack of pleurisy with a large effusion 
on the left side and it was not until several weeks 
later that she again appeared for examination. 

The larynx was unaltered and the breathing fairly 
easy, considering the medium fixation of the right 
cord and the labored heart action due to the large 
pleural effusion. 

The following day, while resting quietly, she was 
attacked by sudden dyspnea and examination re- 
vealed total bilateral abductor paralysis. Tracheot- 
omy was immediately performed but death ensued 
eleven hours later. No autopsy was held. 

Dyspnea of slow development, the essentially 
chronic type, may depend upon any one or more of a 
variety of conditions; a distorted or greatly infil- 
trated epiglottis; swelling of the aryteno-epiglotti- 
dean folds with simultaneous enlargement of the ary- 



94 LARYNGEAL TUBERCULOSIS. 

tenoid cartilages ; bilateral infiltration of the ventricu- 
lar bands; ankylosis of the cricoarytenoids; abductor 
paralysis; subchordal swellings; excessive granula- 
tions and tuberculomata. 

The formation of cicatricial bands between the cords 
is a rare factor and in all likelihood depends upon the 
existence of a mixed lesion, syphilis and tuberculosis, 
for the latter disease alone rarely leads to the forma- 
tion of scar tissue to any considerable extent. 

Ordinarily the process does not advance to the point 
of complete closure; by the time the breathing has 
become labored the general disease has advanced so 
far that the patient succumbs, if not, endolaryngeal 
surgical and medicinal treatment will usually cause 
some retrogression. 

The cases in which tracheotomy is necessitated are 
exceedingly rare, and will become ever rarer as the 
infections are more universally recognized in the early 
stages and therefore are more rationally and persist- 
ently treated. 



CHAPTER VII. 

OBJECTIVE SYMPTOMS. 

Infiltration is the first objective sign of laryngeal 
phthisis. Nearly all observers speak of a tuberculous 
or pre-tuberculons catarrh as the first and therefore 
the mildest form of laryngitis, but the assumption of 
such a condition is entirely without warrant. 

CATARRH. 

Many cases of pulmonary phthisis show a more or 
less catarrhal condition of the laryngeal mucosa. This 
chronic congestion depends upon one or more of sev- 
eral factors; lowered vitality; cough; passage of spu- 
tum; disturbed digestion; naso-pharyngeal catarrh, 
etc.. Neither must it be forgotten that the unhygienic 
conditions which predispose the individual to pulmon- 
ary tuberculosis likewise predispose to chronic ca- 
tarrhal laryngitis. 

While the frequency of this early catarrh must be 
admitted, there is in fact no reason for assuming it 
to be tuberculous and even less for considering it 
" pre- tuberculous." Unless it can be shown that it 
later evolves into true tuberculosis the use of this 
latter term cannot be defended, and this transforma- 
tion, it can be most emphatically stated, does not occur. 

Bacillary infection may take place in catarrhal 



96 LARYNGEAL TUBERCULOSIS. 

membranes the same as in normal membranes, 
but a conversion of a simple catarrh into tuberculosis 
never occurs. 

Many of the cases of so-ealled tuberculous catarrh 
are in reality incipient tuberculous infiltrates, as can 
be demonstrated by the injection of tuberculin, which 
produces a visible increase of hyperemia and swell- 
ing with the occasional eruption of miliary tubercles. 

The clinical history in such a case is different from 
that of a simple inflammation; the congested areas 
are more resistant to treatment, commonly affect only 
one side of the larynx and if neglected advance to 
localized tumefaction and possibly ulceration. 

The most common site of the early infiltrate is the 
interarytenoid sulcus and here the differential diag- 
nosis between early tuberculous infiltration and sim- 
ple catarrhal thickening is exceedingly difficult, for 
it is also one of the points of election for the latter 
condition. 

The most characteristic feature of the tuberculous 
hyperemia is its tendency to affect only one-half of 
the larynx while the catarrhal congestion is always 
bilateral. 

Eedness of one cord, arytenoid, ventricular band, 
etc., is generally indicative of one of four conditions : 
tuberculosis, syphilis, malignancy or traumatism, and 
the differential diagnosis depends upon the accom- 
panying conditions and personal history. 

ANEMIA. 

Perhaps the most widespread of all the fallacies 
concerning laryngeal phthisis is that respecting the 






OBJECTIVE SYMPTOMS. 97 

diagnostic significance of palatal, pharyngeal and 
laryngeal pallor. 

The commonly accepted view is thus expressed by 
J. Solis Cohen: 

"Congestion of the mucous membrane almost 
always marks the earliest recognizable stage of the 
acuter form, while pallor of the mucous membrane 
almost always characterizes the earliest recognizable 
stage of the chronic and more frequent form." 

This early laryngeal pallor, it is claimed, is inde- 
pendent of general pallor and is frequently associated 
with anemia of the pharynx, palate and mouth. 

While the diagnostic worth of this sign has been 
almost universally acclaimed, it merits, according to 
the author's experience, but slight consideration. Its 
frequency in the early stages of the chronic variety 
of phthisis has been greatly exaggerated as is shown 
by the following table based upon six hundred cases 
of comparatively early lesions: 

Total number of cases, 600. 

Hyper- 
Normal. Anemic. emic. 

Palatal Mucosa 264 129 207 600 

Laryngeal Mucosa 38 95 467 600 

Total 302 224 674 1200 

In this table, in so far as possible, every unusually 
acute case has been eliminated. 

These statistics show that pallor of the mucosa is 
far less frequent than congestion even in the essen- 
tially chronic cases. The proportion is about 1 to 3. 
In the far advanced cases the percentage showing 
anemia is necessarily much larger. 

Moreover, in nearly all cases in which this anemia 



98 LAEYNGEAL TTTBEKCULOSIS. 

was present, its value in diagnosis was almost nil, as 
other signs existed which made clear the condition 
without considering the pallor, and in the majority of 
instances the pallor was not localized in the larynx or 
mouth hut was simply an expression of general 
anemia, the conjunctiva, etc., showing like changes. 

Even the first stage of pulmonary tuberculosis, the 
so-called "apical catarrh," is almost always associa- 
ted with signs of general anemia. In these cases, 
according to Grawitz and Strauer, the red cells are 
reduced and the clinical picture is that of pseudo- 
chlorosis. 

A like condition of the laryngeal mucosa is found in 
many normal individuals in whom tuberculosis does 
not later develop; it is almost invariably present in 
general anemia and may be general or of local- 
ized areas. It is an expression of the various 
wasting diseases, diarrhea, etc., and a grayish white 
color of the interarytenoidal mucosa is found in many 
cases of simple chronic catarrh, due to necrosis of the 
epithelial layer. 

Certain tuberculous lesions of an advanced type, 
flabby granulations, warty growths, old infiltrations 
and edematous swellings may be pale and anemic, 
but the areas surrounding and separating the indi- 
vidual lesions are usually somewhat congested. 

It may be said then, that the pallor of laryngeal 
phthisis is nothing more than an expression of general 
tissue waste, and that as such it should lead to further 
investigation as to its probable origin,— «irat that it is 
not pathognomonic of phthisis, is not distinctive and 
not even suggestive, except as any expression of gen- 
era] anemia may be so considered. 



OBJECTIVE SYMPTOMS. 99 

Both the initial catarrh and anemia, unless the 
former can be shown to depend on infiltration, should 
be classed as catarrh or anemia accompanying tuber- 
culosis and not as a tuberculous or pre-tuberculous 
catarrh or anemia. 

Excluding these two conditions four forms of laryn- 
geal phthisis are clinically demonstrable. 

1. The infiltrate. 

2. The ulcer. 
I. The tumor. 

4. The miliary tubercle. 

Certain subdivisions have been attempted, such as 
the " sclereuse et vegetante" of Gouguenheim and 
Glower, the "forme dysphagique" of Ferrand and Bo- 
vet, the hypertrophic form, etc., but such a multiplica- 
tion of terms is inadvisable as they are not distinc- 
tive types but merely variations of the primary groups. 
Granulations, likewise, are a result of ulceration and 
are not to be looked upon as a distinct variety. 

Except in rare instances the individual case does not 
conform exactly to any one of the four types; two or 
more coexist. 

In the incipient stages infiltration alone is generally 
present but with advance of the process some point 
gives way and ulceration complicates the picture. 

The true tumor, alone of the other forms, exists as 
an uncomplicated entity. The miliary type is gener- 
ally found in connection with ulceration and infiltra- 
tion. 

1. The INFILTBATION. 

Infiltration is the earliest and most characteristic of 
the objective symptoms, and may persist indefinitely 






100 



LAKYNGEAL TUBEKCULOSIS. 



without degeneration or the development of other 
signs of local infection. 

Commonly, after a shorter or longer interval, the 
superficial layers of the mucosa succumb to the con- 




Fig. 4. 



stantly increasing pressure of the subepithelial exu- 
date and to the gradual obliteration of the blood ves- 
sels, and the characteristic ulcer appears. 



OBJECTIVE SYMPTOMS. 101 

In the beginning the infiltrate, especially if it is 
limited to the posterior ends of the trne cords or to 
the interarytenoid sulcus, may strongly resemble 
simple catarrhal laryngitis, but in the majority of the 
cases, however, we do not have to deal with such an 
isolated simple process, for there is usually an early 
extension to neighboring structures and contiguous 
tissues, until finally the entire larynx, or a large por- 
tion thereof, is involved, either with or without con- 
comitant ulceration. (Fig. 4.) 

Interarytenoid Sulcus : Infiltration of the inter- 
arytenoidal mucosa is the most frequent and pathog- 
nomonic localization of the earlier manifestations of 
the disease, and often persists unaltered and uncom- 
plicated for many months or years. The comparative 
frequency of this type is shown in the following table : 

Inter- Isolated 

arytenoid Interarytenoid 
Author. Cases. Infiltration. Lesions. 

Keller 48 34 8 

Carmody 81 71 7 

Author 904 640 79 

Total 1033 745 94 

In the early stages of the disease the sulcus is par- 
tially filled by a circumscribed swelling which forms a 
convex projection during deep inspiration. The growth 
may occupy any part of the incisure; it is usually in 
the middle, more seldom upon one side infringing upon 
the corresponding cord, and occasionally upon each 
side giving to the middle portion a sunken, punched 
out appearance. 

The size and character of the infiltrate also varies 
within wide extremes ; in the simplest type it forms a 



102 LARYNGEAL TUBERCULOSIS. 

broad-based, more or less elevated, red or grayish 
white projection covered by a smooth or slightly un- 
even epithelium. (Plate I, Fig. 5.) 

The grayish white color depends upon necrosis of 
the superficial epithelium and is not distinctive of tu- 
berculosis for it also, obtains in other conditions. 

The pallor, therefore, cannot be considered as diag- 
nostic unless it covers a convex infiltrate — and then it 
is the peculiar character of the swelling and not the 
pallor that is distinctive. In some cases the growth is 
an angry red in color. 

The infiltrate frequently departs from this early 
type and takes on the characteristics of a tumor ; it is 
sharply circumscribed, with wide base and pointed ex- 
tremity, and projects slightly into or almost com- 
pletely fills the space between the vocal cords. (Plate 
1, Fig. 6.) 

The free edge of this tumor-like body may be com- 
paratively smooth or distinctly rugous, i. e., covered 
by numerous sharp, ragged, tooth-like projections. 

In rare instances the infiltrate may somewhat resem- 
ble papillomata, the so-called "vegetierende" or "pap- 
illaere" forms. (Plate I, Fig. 7.) 

Vocal Cords: Infiltration of the vocal cords, in the 
early stages, is marked by a diffuse or circumscribed 
redness and moderate swelling strongly suggestive of 
simple chronic laryngitis. 

The tuberculous hyperemia, however, lias a decided 
tendency to involve only one cord or isolated portions 
thereof, or if bilateral, both sides are rarely involved 
to an equal extent, in contrast with the symmetrical 



PLATE I. 

Fig. 5. Broad-based infiltrate of the posterior wall. 
Fig. 6. Tumor-like infiltrate of the posterior wall. 
Fig. 7. Papillomatous infiltrate of the posterior wall. 



PLATE I. 

Fig. 5. Tuberculous infiltrate of the posterior wall. 

Fig. 6. Tumor-like infiltrate of the posterior wall. 

Fig. 7 . Papillomatous-like infiltrate of the posterior wall. 




Fig. 5. 




Fig. 6. 




Fig. 7. 



PLATE I. 



OBJECTIVE SYMPTOMS. 103 

and bilateral distribution of the non-specific inflamma- 
tions. 

The circnmscribed infiltrations are most common on 
the vocal processes, and are generally fonnd in con- 
nection with hyperplasia of the interarytenoidal mu- 
cosa. In such cases the posterior ends of the cords 
are of a pink or deep red color, somewhat uneven or 
notched along the free edge and rounded in form with 
an apparent increase both in width and thickness. 

If the ligamentous portion remains free the condi- 
tion has some resemblance to pachydermia and a 
microscopic examination, if other symptoms are lack- 
ing, may be the only means of determining the nature 
01 the process. 

Before the infiltrate has attained sufficient volume to 
produce evident increase in size the only alteration is 
in color, either as a redness or a loss of the normal 
pearly lustre. Even this slight change, particularly 
when limited to one cord, is highly suggestive. 

In rare instances the anterior commissure is the site 
of a circumscribed infiltrate which affects either the 
angle of the cords or the region immediately above or 
below it. Even when moderate such a thickening in- 
terferes with perfect adduction and vocalization. 

The circumscribed infiltrations rarely persist for 
any considerable time without involving the mid-sec- 
tion of the cord and when this occurs the appearance 
is almost pathognomonic; the cord becomes cylindrical 
in form, convex from free edge to inner margin and 
from end to end, whereby the mid- section appears con- 
siderably wider than the extremities. (Plate 2, Fig. 
8.) 



104 LARYNGEAL TUBERCULOSIS. 

The surface may show a number of oblique dilated 
vessels and the color is either a dull or beefy red. The 
cord is sometimes thickened to many times its normal 
diameter, completely closing the ventricle and obliter- 
ating the line between the cord and ventricular band ; 
in such cases the border between the two is indicated 
by a thin dark line. 

Frequently the free edge of the cord is furrowed 
by a longitudinal groove through the pressure exerted 
by the opposite cord. 

The same condition is simulated by marked swell- 
ing of both the inferior and superior surface of the 
cords, due to the close connection between the free 
edge and the muscular layer whereby it is prevented 
from swelling to a degree equal to that of the other 
segments. 

Arytenoid Cartilages : Isolated infiltration of the 
arytenoid cartilages is comparatively common, but 
frequently there is simultaneous involvement of the 
ary-epiglottic folds. 

In the early stages the process is mostly unilateral, 
in the advanced bilateral, and shows as a single or 
double pear-shaped mass of deep red or purplish color, 
the extremities of which extend upward and outward 
until lost in the ary-epiglottic fold. (Plate 2, Fig. 9.) 

If the infiltrate is of long standing and large propor- 
tions the mucosa becomes pale and translucent, the 
i nterary tenoid sulcus partially obliterated and 
Wrisberg's cartilage hidden. Movement of the cords 
is mechanically hindered by the enlarged cartilage as 
well as by ankylosis of the crico-arytenoidal joint. 
Acute inflammatory swelling of one or both arytenoids 



PLATE II. 



Fig. 8. Infiltration of the vocal cords and interarytenoid 
sulcus. The cords have assumed the typical 
cylindrical form. 

Fig. 9. Infiltration and congestion of the right arytenoid 
cartilage and ventricular band. The correspond- 
ing cord is ulcerated along the free edge and 
somewhat thickened. 

Fig. 10. Edema and colossal swelling of both arytenoid 
cartilages. 



PLATE II. 

Fig. 8. Cylindrical vocal cords. 

Fig. 9. Ulceration of the right vocal cord and infiltration 
of the corresponding arytenoid and ventricular 
band. 

Fig. 10. Edema of the arytenoid cartilages. 




Fig. 8. 




Fig. 9. 




/<K\-^V L_ l_-V — C=> (El 



Fig. 10. 



PLATE II. 



OBJECTIVE SYMPTOMS. 



105 



during the course of chronic tuberculous inflammation 
frequently occurs. 

Aryteno-epiglottidean Folds: In these folds in- 
filtration reaches a high degree owing to the abundant 
loose, submucous tissue. It is usually bilateral but 
may be limited to one side, and is always found in 
combination with either arytenoidal or epiglottic dis- 
ease, and frequently both. 




Fig. 11. 

In connection with bilateral arytenoidal swelling the 
appearance is absolutely pathognomonic. On either 
side the pyriform or flask-shaped tumors encroach 
upon the lumen of the upper aperture, which is still 
further closed by the enormous globular masses repre- 
senting the arytenoids proper which meet in the mid- 
dle line posteriorally and extend back into the 
pharynx. 



106 LARYNGEAL TUBERCULOSIS. 

There is usually some edema present giving to the 
otherwise red body a pale and translucent appearance. 
Such cases generally have a fatal termination and their 
course is attended by severe dysphagia and some dysp- 
nea. (Plate 2, Fig. 10.) 

Epiglottis : Widespread infiltration of the epiglot- 
tis, in the great majority of instances, is a late manifes- 
tation although now and then it is met as an early or 
even the primary laryngeal focus. 

In the milder forms the edge is swollen to several 
times the normal thickness and has the appearance of 
being rolled upon itself ; the color may be either bright 
red or pale. (Fig. 11.) 

The swelling is often almost as great as that of the 
ary-epiglottic folds, giving it the so-called "turban" 
or "omega" shape. (Plate III, Fig 12.) 

The infiltration is sometimes limited to one 
half the organ (Plate III, Fig. 13.) and I have 
had occasion to observe several unusual cases 
in which there has been no swelling except 
in the space between the epiglottis and base 
of the tongue, extending, with gradually decreasing 
distinctness, toward the free edge. 

Severe pain almost always marks epiglottic involve- 
ment and even slight infiltration destroys its mobility. 

Ventricular Bands: A considerable percentage 
of all cases of tuberculous laryngitis show some infil- 
tration of the ventricular bands, which may be the 
first localization of the process in the larynx. As a 
rule it is of moderate extent but occasionally reaches 
large proportions. 

I n the latter case ilie vocal cord of the corresponding 



PLATE III. 



Fig. 12. "Turban" or "Omega" shaped epiglottis. Both 
cords show slight ulceration and the arytenoid 
cartilages are uneven and nodular. 

Fig. 13. Warty infiltration of the left side of the epiglot- 
tis. The corresponding arytenoid is slightly 
thickened, the interarytenoid sulcus infiltrated, 
and both cords congested. 

Fig. 14. Bilateral infiltration of the ventricular bands. 
The left vocal cord and interarytenoidal mucosa 
are slightly ulcerated. 



PLATE III. 

i 

Fig. 12. Turban-shaped epiglottis. 

« 
Fig. 13. Warty infiltration of the epiglottis. 

Fig. 14. Bilateral infiltration of the ventricular bands. 




Fig. 12. 




Fig. 13. 



(f^N>V>v I— 1— V - CD <sl 



Fig. 14. 



PLATE 



OBJECTIVE SYMPTOMS. 107 

side may be completely hidden; if of less extent one or 
both ends of the cords remain visible. (Plate III, Fig. 
14.) 

In bilateral swelling the bands sometimes meet in 
the median line, causing some dyspnea and aphonia, 
or usurping the functions of the true cords when these 
are destroyed, they produce a rough, suppressed voice. 
The anterior wall of the larynx is involved in a small 
proportion of the cases. 

Subglottic Region : With the exception of the form 
known as "chorditis vocalis inferior" or "laryngitis 
hypoglottica, ' ' infiltrations in the subglottic region are 
rare. 

Laryngitis hypoglottica conveys the impression of 
an extra vocal cord parallel with and slightly beneath 
the true cord. It is either single or bilateral, and of a 
bright or pale red color, and originates either from an 
extension of the infiltrate from the inferior surface of 
the true cords or by primary deposit. 

Instead of forming distinct bands the infiltrate may 
almost completely encircle the larynx. (Plate IV, Fig, 
15.) 

2. THE ULCER. 

As infiltration is considered the first objective sign 
of laryngeal phthisis, so ulceration may be looked upon 
as the second distinctive manifestation. 

Other conditions sometimes intervene between the 
stages of infiltration and ulceration, or the latter may 
never occur, but in the average progressive case such 
a sequence is the rule. 

The typical ulcer is always dependent upon infil- 



108 LAKYKTGEAL TUBEECULOSIS. 

tration through the disintegration of caseated tuber- 
cles, and the first changes occur in the subepithelial 
tissues. 

There is another variety, however, of characteristic 
appearance, due to sputal infection, that of necessity 
begins in the epithelium itself. The first of these is 
marked by three characteristics: the ill-defined mar- 
gins, irregular and uneven, the so-called worm- 
eaten appearance; the presence of granulations 
and of miliary tubercles. 

The edges are occasionally prominent and partially 
overlap and obscure the base, hence the true size and 
limits of the ulcer cannot always be definitely deter- 
mined. 

The second and more pathognomonic peculiarity is 
the presence of numerous small, red granulations 
upon the floor and around the margins of the ulcers. 

The third, and absolutely diagnostic feature, is the 
small grayish or yellowish spot known as the miliary 
tubercle. 

The base is almost always covered by a tenacious 
yellowish or dirty white exudate of pus and dead 
epithelial cells. 

The most frequent sites of such ulcers are the vocal 
cords, interarytenoid sulcus, arytenoid cartilages 
and epiglottis. They occur as well, however, upon all 
segments of the larynx. 

The type of the resultant ulcer depends in large 
measure upon the locality involved; in segments rich 
in glands and covered by cylindrical epithelium it is 
deeper and more crater-like in form than where it 
involves areas covered by pavement epithelium. Ex- 



PLATE IV. 

Fig. 15. Subglottic infiltration. 

Fig. 16. Ulcerated infiltrate of the interarytenoid sulcus 

Fig. 17. Ulceration at corresponding points of both vocal 
cords. 



PLATE IV. 

Fig. 15. Subglottic infiltration. 

Fig. 16. Ulcerated infiltrate of the interarytenoid sulcus. 

Fig. 17. Ulceration at corresponding points of both cords. 




Fig. 15. 




Fig. 16. 




Ci^ 



Fig. 17. 



PLATE IV. 



OBJECTIVE SYMPTOMS. 109 

tension occnrs throngh confluence of contiguous ulcers 
and the slow superficial extension of the individual 
areas. 

Arrosion Ulcers : Non-tuberculous ulcers may 
occur in the larynges of phthisical subjects the same 
as in other inflammatory conditions and heal without 
subsequent infection by the bacillus, as is shown by 
their occasional prompt disappearance under simple 
treatment, but early invasion of the necrotic areas by 
the tubercle bacilli, however, is so constant that it is 
a safe rule to regard all such ulcers as tuberculous. 

The superficial tuberculous ulcers, due primarily to 
the action of the irritant sputum with early bacillary 
infection, occur mostly upon the tip of the epiglottis, 
the vocal cords, inner sides of the arytenoids and the 
posterior and lateral walls of the trachea, and are 
usually found in connection with widespread pulmon- 
ary involvement with profuse secretions. 

They appear at numerous points or in groups of two 
or more, are essentially superficial and are round, 
oblong or irregular in shape, the edges are sharp and 
brilliantly inflamed, and they spread with great ra- 
pidity, largely through the confluence of contiguous 
foci. The base is covered by an elevated membrane 
strongly resembling that due to diphtheria, and the 
granulations of the true ulcer are lacking. 

While the clinical picture is usually distinctive, it 
is not possible, without histologic demonstration of 
miliary tubercles about or on the base, to definitely de- 
termine their true nature. 

That ulcers of this type exist in the larynges of 
tuberculous individuals is strongly denied by many 



110 LAKYNGEAL TUBEKCULOSIS. 

modern observers, but what other theory will explain 
their rapid cicatrization which occnrs frequently after 
simple treatment and of times even spontaneously! 

Moreover, as has already been shown, ulcers of a 
like nature are sometimes found in the air passages 
of individuals to whom no suspicion of phthisis can 
attach, and upon other mucous membranes as well, and 
why, therefore, should the possibility of their occur- 
rence in the larynges of consumptives, where all the 
conditions favorable to their development are present, 
be denied? 

The character of the individual ulcer, whatever the 
type, depends upon the nature of the tissue involved 
and, therefore, can be best described by taking up in 
turn the various segments of the larynx as was done 
in the discussion of infiltrations. 

Inter arytenoid Sulcus : As the posterior wall 
is one of the points of election for infiltration so it 
is likewise a favored site for ulceration. The early 
ulcer is frequently overlooked because the prominent 
borders or large granulations about the edges partially 
obscure it unless the methods of Killian or Kirstein 
are used. For the same reason the necrosis is gen- 
erally much more extensive than is apparent in the 
reflected image. 

The first visible change in the infiltrated tissue is a 
gradual grayish or bluish white discoloration of the 
convex border, due to the pressure of the subepithelial 
exudate with resultant necrosis on the surface. 

As this gives way the formerly more or less smooth 
surface becomes indented by deep clefts, giving rise 
to the so-called "saw tooth" appearance, or if only 



PLATE V. 

Fig. 18. Ulceration of the free edges of the vocal cords, 
giving the so-called "saw-tooth" appearance. 

Fig. 19. Cleft cord. 

Fig. 20. Chorditis granulosa. 



PLATE V. 



Fig. 18. "Saw tooth" cords. 

Fig. 19. Cleft cord. 

Fig. 20. Chorditis granulosa. 




Fig. 18. 




Fig. 19. 




(AVAULV-Dgl 



Fig. 20. 



PLATE V. 



OBJECTIVE SYMPTOMS. Ill 

the middle surface is involved, the convex edge appears 
as though a portion had been removed by a punch. 

The base shows numerous small red granulations 
that about the edges reach a considerable size and ex- 
tend like sharp ragged teeth into the lumen of the 
larynx. (Plate IV, Fig. 16.) 

These granulations ulcerate in turn and are sur- 
rounded by new granulations, giving the impression 
of " a chain of mountains with narrow valleys running 
between them. ' ' — Friedrich. 

In cases running a rapid course the granulations 
mav be so extensive and numerous as to stronglv re- 
semble papillomata, or in other instances they become 
edematous and almost fill the glottis. 

Vocal Cords : Ulceration of the interarytenoidal 
mucosa is nearly always complicated by some destruc- 
tion of the vocal cords and particularly of their pos- 
terior ends. 

Frequently this cord necrosis is hidden by overlap- 
ping granulations of the posterior wall and come into 
view only when these are removed ; in other instances 
the yellowish exudate covering most of the necrotic 
areas, if the ulcer is shallow, gives the impression ot 
a normal condition. 

The ulcers vary in characteristics according to their 
location upon the cord, the free edge, upper or inferior 
surface. 

In many cases they occur upon symmetrical points 
of both cords, generally at the point of juncture of the 
middle and anterior third. (Plate IV, Fig. 17.) 

On the free edge there may be one or more small 
necrotic points separated by areas of apparently nor- 



112 LAKYNGEAL TUBEKCULOSIS. 

mal or infiltrated tissue, or the entire margin may be 
converted into a long, narrow, irregular slough com- 
pletely destroying the normal contour of the cord, 
(Plate V, Fig. 18.) 

Upon the vocal processes there is a characteristic 
type in which upon the most prominent point of the 
infiltrate a hollowing or reaming-out occurs, forming 
a triangular defect with the apex anterior. The edges 
are smooth and clear-cut and the base yellow in color. 
It is this form which bears such a marked resemblance 
to pachydermia but in the latter disease true ulcera- 
tion never occurs. 

An ulcer occasionally forms in the groove 
formed along the edge of the infiltrated cord by the 
pressure of the opposite band, and gives to it a cleft 
or divided appearance. (Plate V, Fig. 19.) 

Schech has described a case of complete separation 
of the cord from the vocal process. 

Because of the small amount of submucous tissue at 
this point and the superficial position of the arytenoid 
cartilage, ulcers of the vocal processes frequently lead 
to perichondritis. 

Ulcers occasionally form along the entire upper sur- 
face of the cord converting it into a series of longi- 
tudinal folds; if the free edge and inner margin are 
involved the uninvaded middle portion projects promi- 
nently above the level of the remaining segments; if 
the middle section only is ulcerated the margins ap- 
pear somewhat elevated. 

Besides these definite types there are many others 
of various forms — mostly round, oval or irregular. 

Ulcerations on the inferior surfaces of the cords 



OBJECTIVE SYMPTOMS. 



113 



are not uncommon, bnt are rarely recognized until 
they have reached large proportions or until the ac- 
companying granulations extend beyond the free 
edges. The granulations occasionally become so ex- 





#^*- 






; 


i *■' '' ■ H 


|^1 




* 


VM ' 








i 




Mk_. 


JH 


Hub jt 








^HBH ft^vjM 




k : V 




^^1 


T ^ 





Fig. 21. 



cessive as to completely cover the cord or to till the 
glottis sufficiently to produce dyspnea. 

In certain cases the upper surface is studded with 
small granulations leading to the condition known as 
"chorditis granulosa." They occasionally resemble a 



114 LAKYNGEAL TUBEKCULOSIS. 

string of beads strung along the inner margin of the 
cord. (Plate V, Fig. 20.) 

Epiglottis : Infiltration of the epiglottis is almost 
always soon followed by ulceration. (Fig. 21). The 
laryngeal surface is the favored site but the free edge 
is also frequently attacked, especially by that type 
known as the aphthous or arrosion ulcer. If such occur 
the entire free edge is dotted with small, flat, white, 
smooth points of necrosis. 

The intermediate mucosa is red and swollen and the 
whole surface is bathed in tenacious muco-pus. 

The deeper ulcers lead to marked distortion and 
destruction of the entire organ. 

Contrary to the commonly accepted view that tuber- 
culosis rarely leads to complete destruction, in contrast 
with syphilis (Schech, Lake and others), it has been 
the author's experience that the entire organ may melt 
away with great rapidity. At the present time he has 
under occasional observation a man of 29 years in 
whom there is only a small stump representing what 
formerly was the epiglottis. The organ was entirely 
destroyed in the winters of 1903 and 1904 and com- 
plete arrest ensued. A considerable number of such 
cases have been seen. (Plate VI, Fig. 22.) 

Instances in which the entire free edge or one-half 
of the organ has disappeared are relatively common 
in advanced cases. (Plate VI, Fig. 28.) 

Defects, such as "V" shaped incisures, etc., are 
often seen. (Plate VI, Fig. 24.) 

If limited to the lower part of the laryngeal surface 
the ulcers may at times be recognized with difficulty 
owing to the immobility consequent upon widespread 



PLATE VI. 



Fig. 22. Almost complete destruction of the epiglottis 
The process was arrested and did not recur de- 
spite subsequent infection of the arytenoids, the 
aryepiglottic folds and the ventricular bands. 

Fig. 23. Destruction of the entire right half of the 
epiglottis. 

Fig. 24. "V" shaped defect in the epiglottis due to cir- 
cumscribed ulceration, with extensive ulceration 
of the corresponding arytenoid. 



PLATE VI. 

Fig. 22. Complete destruction of the epiglottis. 
Fig. 23. Destruction of one-half the epiglottis. 
Fig. 24. "V" shaped defect of the epiglottis. 



Fig. 22. 



Fig. 23. 







Fig. 24. 



PLATE VI. 



OBJECTIVE SYMPTOMS. 115 

infiltration, to the overhang of a rounded edge or to 
exuberant granulations. These obstacles can usually 
be overcome ; if not, the epiglottis can be retracted, or 
a pledget of cotton swept over the hidden surface may 
show blood. 

Primary ulceration of the lingual surface is one of 
the rarest manifestations of the disease and I have 
seen but one such case, combined in this instance with 
ulceration of the base of the tongue. (Plate VII, Fig. 
25.) In several additional cases there was ulceration 
of the lingual surface secondary to extensive disease 
of the laryngeal surface and free edge. 

Widespread epiglottic involvement is usually sec- 
ondary to other laryngeal foci but occurs occasionally 
as the primary localization. 

An hitherto unobserved type of laryngeal involve- 
ment was recently brought to the author's attention 
by Dr. T. E. Carmody. The lingual glands were 
somewhat swollen, there was moderate infiltration of 
the Lig. Glosso-Epiglotticum, and the free edge of the 
epiglottis was greatly thickened and rolled upon itself, 
making a sigmoid curve. 

The unique feature consisted of two complete per- 
forations, the one located at the tongue border a little 
to the right of the median line, the other near the mid- 
dle and somewhat closer to the free edge. Both openings 
were irregularly oval in shape and the upper median 
one was approximately one-sixth of an inch, the lower 
lateral one-quarter of an inch in diameter. 

The latter appeared as though it had originated on 
the laryngeal surface, the opening at this point being 
round and smooth while on the lingual side it opened 



116 LARYNGEAL TUBERCULOSIS. 

out in a funnel shape, made a deep groove and ex- 
tended slightly into the base of the tongue. The origi- 
nal point of ulceration in the second opening could not 
be determined although owing to the greater spread- 
ing of the lips on the tongue side it seems probable that 
it started there. "Within the canals could be seen the 
ragged edges of the necrotic cartilage. (Plate VII, 
Fig. 26.) 

The probability of a syphilitic taint could be almost 
definitely eliminated, and there were other well marked 
signs of tuberculosis both in the lungs and larynx. 

The entire epiglottis was amputated and numerous 
sections, embracing both the edges of the perforations 
and the infiltrated free edge, showed typical tuber- 
culous changes. 

Tuberculous perforations of the palate, the only 
analogous condition, are extremely rare, not more than 
fifteen cases having been reported, and one of the diag- 
nostic features rests upon the fact that they are always 
single in contradistinction to the common multiple 
openings of syphilis, so this case is doubly unique, 
first, because of the organ affected, and secondly, on 
account of the openings being two in number. 

Ventricular Bands: Isolated ulceration of the 
ventricular bands is comparatively rare. There is 
usually simultaneous involvement of other segments 
of the larynx and there is likewise a strong tendency to 
spread and involve contiguous tissue. 

All forms of ulceration occur but most frequently 
there is seen the flat, round, superficial, diffuse va- 
riety with white base, that boars a striking resemb- 



PLATE VII. 



Fig. 25. Ulceration of the lingual surface of the epiglot- 
tis and base of the tongue. 



Fig. 26. Double perforation of a greatly infiltrated epi- 
glottis (Dr. Carmody's case). 

Fig. 27. Extensive ulceration of both ventricular bands. 



PLATE VII. 

Fig. 25. Ulceration of the lingual surface of the epiglottis 
Fig. 26. Tuberculous perforations of the epiglottis. 
Fie. 27. Ulceration of both ventricular bands. 




Fig. 25. 




Fig. 26. 



".3k 




^AVA 1_ 1— T" — P<bV 



Fig. 27. 



PLATE VII, 



OBJECTIVE SYMPTOMS. 



117 




Fig. 28. 



118 LAKYNGEAL TUBEKCULOSIS. 

lance to the necrosis of diphtheria or that due to con- 
centrated silver solutions. (Plate VII, Fig. 27.) 

Frequently the bands are dotted with small round 
ulcers giving the parts the so-called "sieve" appear- 
ance; confluence of these leads to the formation of a 
single flat, round or irregular ulcer that involves the 
entire band or a considerable portion thereof. 

Because of the large amount of loose submucous 
tissue severe swelling always accompanies deep ul- 
ceration, and the latter may be completely hidden by 
the protruding mucosa and granulations. (Fig. 28.) 

I have s^en only one case in which ulcerations of the 
band were unaccompanied by other evidences of the 
disease. 

Occasionally the anterior wall of the larynx is cov- 
ered with minute ulcers that are easily overlooked be- 
cause of the overhang of the epiglottis. 

Arytenoids and Ary epiglottic Folds: Ulcera- 
tion of the aryteno-epiglottidean folds usually occurs 
late in the course of the disease and is generally su- 
perficial ; on the arytenoids, particularly the inner sur- 
faces, ulceration is both frequent and early. In the 
former situation the ulcers are generally superficial, 
flat and of great size. (See Fig. 21.) 

On the arytenoids, in addition to the part already 
mentioned, they appear on the summit, base and sides, 
and frequently lead to perichondritis and chondritis. 
The favored site is the point of convergence of the 
cord, arytenoid, ventricular band and interarytenoid 
sulcus. 

In many cases the cartilages and folds are converted 
into large irregular fungous-like bodies through the 



OBJECTIVE SYMPTOMS. 119 

presence of numerous ulcers and granulations with 
their attendant edema, that bear but slight resemb- 
lance to the normal structures. (Plate VIII, Eig. 29.) 

Subglottic Ulceration: Subchordal ulceration is 
comparatively rare and of late development. Jurasz 
has described a form pathognomonic of tuberculosis. 
It consists of a deep ulcerated groove running parallel 
with and inferior to the true cord that forms, as it 
extends, a sort of pocket resembling an artificial sub- 
chordal Ventriculus Morgagni. 

The cord is apparently thrown into two folds, the 
upper one the true cord, the lower the linear sub- 
chordal mucosa below the pocket. 

Ulceration may extend about the entire lumen of the 
larynx imediately beneath the cords forming a per- 
fect ring. 

Both infiltration and ulceration in the subglottic re- 
gion are clinically rare — (in 3,994 lesions of the larynx, 
involvement of this region was found only 55 times) — 
but they are frequently found post mortem. 

Tracheal ulceration, in combination with the various 
laryngeal lesions, is occasionally seen. (Plate VIII, 
Fig. 30.) 

CONDITIONS SECONDARY TO ULCERATION 
AND INFILTRATION. 

Perichondritis is a common sequela of ulceration or 
extensive infiltration and involves the arytenoids more 
frequently than all the other cartilages combined. In- 
volvement of these cartilages can usually be attributed 
to ulcerative processes of the vocal processes, the aryt- 
enoidal mucosa, the posterior wall and more rarely 
the sinus pyriformis. 



120 LARYNGEAL TUBERCULOSIS. 

On the vocal processes especially the cartilage is 
superficial and exposed, so ulceration readily spreads 
to and involves the perichondrium. 

Laryngoscopic examination rarely gives an exact 
conception of the existing conditions for uncompli- 
cated perichondrial inflammation offers few distinc- 
tive signs; it often simulates infiltration to such an 
extent that it is impossible to distinguish between 
them. 

Swelling of the cartilage in connection with edema 
of the aryepigiottic fold is the most frequent manifes- 
tation, but cannot be considered distinctive as it also 
occurs in cases of simple infiltration. 

Likewise an edematous swelling of the cartilage, 
commonly considered pathognomonic, may occur in- 
dependently of perichondrial involvement and is only 
strongly suggestive when due to ulceration. 

The most valuable single sign is fixation of the 
crico-arytenoidal joint; immobility alone, however, is 
in no way distinctive for it may be the result of simple 
infiltration of the arytenoidal mucosa. 

The coexistence of several of these symptoms, i. e., 
sudden painful swelling of the cartilage, fixation and 
edema of the aryepigiottic folds or ventricular bands, 
either one-sided or bilateral, definitely establishes the 
diagnosis. 

When the process has advanced to the stage of ne- 
crosis and abscess formation the diagnosis offers few 
difficulties. 

The abscess opens either near the cartilage of San- 
torini or at the vocal process and pus exudes upon 
pressure or during phonation and deglutition. 



OBJECTIVE SYMPTOMS. 121 

Through the opening the ragged, necrotic cartilage 
is sometimes seen and small or large fragments may 
be thrown off with the pus. 

The separation and expulsion of the pieces of carti- 
lage, if considerable fragments are detached, may pro- 
duce death through asphyxiation; on the other hand, 
expulsion has taken place without any subjective symp- 
toms. 

Subsequent examination shows a marked depression 
in the region of Santorini's cartilage. 

Perichondritis of the cricoid is rare and as a rule 
involves only one-half the cartilage. 

It is usually found in association with perichondritis 
of the corresponding arytenoid and depends upon the 
same cause, ulceration of the posterior wall and pos- 
terior ends of the vocal cords or of the arytenoids. 

Certain exceptional cases may be traced to non-ul- 
cerative infiltrations of the cartilage. 

Almost typical of cricoid involvement is the long, 
narrow, glazed subchorial tumor extending beyond the 
free edge of the cord, particularly if associated with 
swelling of the corresponding arytenoid. 

Ankylosis of the crico-arytenoidal joint, due to sep- 
aration of the crico-arytenoideus or to necrosis, and 
edema of the ventricular bands, ventricles or true 
cords, are common sequelae and help to differentiate 
the condition from subchordal infiltration. 

When suppuration has occured respiratory fluctua- 
tion may be noted, the tumor increasing in size during 
inspiration and receding with expiration. 

Eupture occurs either at the vocal process or at the 
under side of the cord, and expulsion of large pieces 



122 LAKYNGEAL TUBEKCTJLOSIS. 

of necrotic cartilage may subsequently occur with sink- 
ing of the superimposed parts. 

In rare instances the pus follows the ring portion 
and discharges into the front of the throat or into 
the trachea. 

Perichondritis of the epiglottis almost invariably 
follows ulceration and in the early stages is not to be 
distinguished from uncomplicated infiltration. 

Tuberculous epiglottic perichondritis never leads to 
abscess formation and in consequence only molecular 
necrosis is met ; the formation of large sequestra never 
occurs. 

The process is essentially chronic and is marked by 
a considerable increase in thickness, the epiglottis 
often reaching to the ventricular bands, the pharyngo- 
and aryepiglottic folds and the arytenoid cartilages. 
In the ulcerated areas the ragged edge of the cartilage 
is often visible. (See Fig. 21.) 

Thyroid perichondritis is very rare and almost 
always results from deep ulcers of the ventricular 
bands or anterior commissure, although in extremely 
rare instances it may apparently be the first and only 
larvngeal focus. 

When the inner side is involved examination shows 
immense swelling of the entire half of the larynx with 
immobility of the corresponding vocal cord. The swell- 
ing usually extends to the subglottic region in the 
vicinity of the anterior commissure. (Plate IX, Pig. 

31.) 

When suppuration ensues pointing of the abscess 
and rupture occur either above or below the commis- 
sure or in the anterior part of the ventricle. The in- 



PLATE VIII. 



Fig. 29. Ulceration and infiltration of the upper aperture 
of the larynx. The arytenoid cartilages are con- 
verted into a fungoid mass, and the edge of the 
epiglottis shows several points of ulceration. 

Fig. 30. Tuberculous ulceration of the trachea. 



PLATE VIII. 



Fig. 29. Ulceration and infiltration of the upper aperture 

of the larynx. 
Fig. 30. Tuberculous ulceration of the trachea. 




Fig. 29. 




Fig. 30. 



C^X^>OsL 



PLATE VIII. 



OBJECTIVE SYMPTOMS. 123 

flamniation may extend through the cartilage and in- 
volve the outer plate with the formation of a circum- 
scribed or diffuse fluctuating tumor beneath the skin. 

External pressure causes pus to exude into the 
larynx although this may also happen when the inner 
plate alone is diseased. Rupture may be followed by 
the formation of a fistula through which a probe will 
pass from the skin surface into the interior of the 
larynx. 

Adhesions : The formation of bands of cicatricial 
tissue, as a result of tuberculous ulceration, is exceed- 
ingly rare and few observers have noted its occurrence. 
Moritz Schmidt has described several cases in which 
bands of connective tissue formed between the poste- 
rior ends of the vocal cords and the posterior wall 
without, however, extending sufficiently to cause any 
interference with respiration. 

Rosenheim of Baltimore (Laryngoscope, September, 
1906), recorded a case in which the tuberculous tissue 
formed a web between the anterior two-thirds of the 
cords. In addition to the web there was marked in- 
filtration of both arytenoids and ventricular bands, 
and the vocal cords were slightly infiltrated and in- 
jected. The web was of a reddish color and firm on 
palpation. Microscopic examination of tissue removed 
from the arytenoid, as well as from the web, showed 
typical tuberculous changes. 

I have seen one remarkable case of this kind through 
the courtesy of Dr. T. E. Carmody. The patient, a 
woman of thirty-four years, had had throat trouble of 
nearly two years' duration. At the time of her first 
examination there was tuberculous ulceration of the 



124 LAKYNGEAL TUBEKCULOSIS. 

cords at the anterior commissure, of the left ventricu- 
lar band, interarytenoid sulcus and left subglottic 
space. She disappeared for one year when examina- 
tion showed the following conditions : 

The vocal cords are united by two webs, one occupy- 
ing the anterior one-fourth of the cords, the other the 
posterior one-third. The posterior web is attached 
firmly to the posterior wall. The middle third of the 
left cord is drawn down by adhesions until it occupies 
a lower plane than the extremities and the opposite 
cord. (Plate IX, Fig. 32.) 

The webs are firm in texture and reddish white in 
color. The picture is typical of syphilitic disease but 
there is an absence of any other signs of specific trou- 
ble : there are no enlarged glands or other scar tissue ; 
she lias had two healthy children and denies all history 
of syphilis. Specific treatment has had no effect. On 
the other hand, there is advanced tuberculosis of both 
lungs, bacilli are constantly present in the sputum 
and microscopic examination of tissue removed from 
the larynx shows typical tuberculous changes. There 
has been considerable dyspnea for the past six 
months. Despite the clinical history and microscopic 
findings, one is inclined to consider the case one of 
mixed infection. 

3. THE TUMOR. 

Whether or not tuberculous tumors of the larynx 
are to be looked upon as an extremely rare, or merely 
a relatively uncommon manifestation of phthisis, de- 
pends upon the interpretation of the term tubercu- 
loma. 



OBJECTIVE SYMPTOMS. 125 

If the name is limited to those tumor-like growths 
characterized by absence of bacilli, giant cells and tu- 
bercles, then even the most experienced laryngologist 
will rarely have seen a single example. If, however, 
the term be accepted in its wider significance as includ- 
ing all growths resembling true tumors, where preced- 
ing ulcerations can be definitely eliminated, their com- 
paratively frequent occurrence must be admitted. 

The laryngeal tuberculoma is usually secondary 
but may precede any demonstrable pulmonary lesion: 
it is sometimes the only laryngeal focus and shows a 
marked predilection for individuals of an age consid- 
erably younger than that at which other tuberculous 
lesions most commonly occur. 

They attack all parts of the larynx but not to an 
equal extent, and are most common in the ventricles, 
upon the posterior wall and under the angle of the 
glottis. Very rarely they occur upon the epiglottis, 
the ventricular bands and vocal cords. 

Panzer (Wien, Med. Wochen., Nr. 3-5, 1895), has 
described three cases of tuberculous polypi in the 
latter region. 

The diagnosis is usually difficult and when unaccom- 
panied by other local or general signs of the disease 
often impossible without microscopic examination of 
excised portions of the growth. 

In shape they may be round, oval, oblong, lobulated 
or pedunculated, and in color vary from reddish gray 
to yellow. They may exist singly or in clusters, in 
size vary from a pin's head to a cherry or hickory-nut, 
and in texture be friable or firm and tough. The 
overlying mucosa is always normal and the surface 



126 LARYNGEAL TUBEKCULOSIS. 

may be either warty or smooth. The development is 
very slow. (Plate IX, Fig. 33.) 

A common sonrce of error in diagnosis is the mistak- 
ing of such conditions as sharply circumscribed infil- 
trates, prominent granulations, tumors, gummata, lu- 
pus, &c, for true tumors. 

Trautmann (Archiv. fur Laryngologie, Bd. XII, 
1902) has grouped these widely differing types into 
the following classes : 

( 1 ) . ' ' Type d ' Avellis, ' ' which resembles true fibro- 
mata. 

( 2 ) . " Phthisis pseudo-polypeuse ' ' of Grouguenheim 
and Tissier. 

(3). Recurrent tumors of slow growth, unaccom- 
panied by ulceration and characterized by absence of 
bacilli, giant cells or tubercles. 

To these groups should be added another, including 
the warty growths of the interarytenoid sulcus, for in 
many instances they conform perfectly to the condi- 
tions generally considered essential. 

4. THE MILIARY TUBERCLE. 

Miliary tuberculosis of the larynx is so rare that 
even its occasional occurrence has been denied by many 
observers. 

Undoubtedly many cases so recorded are not ex- 
amples of miliary tubercles at all, but minute super- 
ficial abscesses, obstructed glands, transparent lymph 
follicles (Schnitzler) and small pale granulations. 

That true miliary tubercles are occasionally seen, 
however, can no longer be doubted although they 
must be classed as the most infrequent form of laryn- 
geal phthisis. 



PLATE IX. 



Fig. 31. Perichondritis of the right half of the thyroid 
cartilage. 



Fig. 32. Extensive cicatrization and web formation, due 
to mixed tuberculosis and syphilis. 

Fig. 33. Tuberculoma of the anterior commissure. 



PLATE IX. 

Fig. 31. Thyroid perichondritis. 

Fig. 32. Scar tissue due to mixed tuberculosis and 
syphilis. 

Fig. 3v3. Tuberculoma at the anterior commissure. 




Fig:. 31. 




Fig-. 32. 






4 




Fig. 33. 



PLATE IX. 



OBJECTIVE SYMPTOMS. 127 

Two factors contribute to the rarity of their clinical 
recognition: their identity is soon lost by conversion 
into nlcers or they promptly disappear through ab- 
sorption. 

When present they appear as minute gray or yellow 
nodules upon the base or around the edges of ulcers, 
over infiltrated areas or upon projecting granulations. 
According to Moritz Schmidt, they frequently become 
prominent during treatment by tuberculin. 

The possibility of clinically recognizing miliary tu- 
bercles has been denied by Heinze on the ground that 
they are invisible to the naked eye even when fresh 
ulcerations are removed and examined post mortem. 

On the other hand Moritz Schmidt reports a case 
of extensive ulceration of the ventricular band due to 
the breaking down of some twenty miliary nodules, 
and Ph. Schech has described cases of infiltration of the 
false cords where the miliary nodules were so numerous 
that they resembled grains of sand thickly sprinkled 
over the mucosa. 

Clinical and anatomical examination showed them 
to be tubercle conglomerations that later ulcerated 
and left numerous small apertures resembling a sieve. 

Angelot, Orth and Catti (Wein, Klin. Woclien., 
1894) have reported cases of acute miliary tuberculo- 
sis beginning in the larynx and pharynx. 

Catti says the laryngeal symptoms may be so severe 
as to simulate diphtheria and effectually mask the gen- 
eral symptoms. 

The author has seen several cases so distinctive that 
no doubt could attach to the diagnosis. (Plate XVI, 
Fig. 51). 



128 LARYNGEAL TUBERCULOSIS. 

One of these, a railroad traffic agent of 34 years, 
with consolidation of the right upper lobe and bilateral 
arytenoidal infiltration, developed sudden severe pain 
in the larynx with a rise of temperature from normal to 
102°. The infiltrated arytenoid cartilages showed in- 
numerable minute white spots with intense congestion 
of the surrounding mucosa. The larynx had been ex- 
amined a few days before and showed nothing of this 
nature. Within a few days the nodules over the right 
cartilage ulcerated and those on the left disappeared. 
In six weeks the ulcer healed. 

A second case occurred in a young electrical engin- 
eer, 24 years of age. When first seen there had been 
hoarseness for one month and severe dysphagia for 
four days. Examination showed numerous miliary tu- 
bercles of the left ventricular band which was chron- 
ically infiltrated. The posterior ends of both cords 
were ulcerated and the left arytenoid was moderately 
enlarged and covered by miliary tubercles. Tempera- 
ture 104 1-2, pulse 130. There was slight consolida- 
tion of the right upper lobe and the general condition 
was excellent. 

Within thirteen days all the spots had disappeared 
and both the pulmonary and laryngeal disease im- 
proved steadily for five months, when he suffered from 
a severe attack of ptomain poisoning. Again there 
was an eruption of miliary tubercles on both aryte- 
noids but the band was not invaded. The attack was 
ushered in by chills, dysphagia and high temperature. 

The pulmonary condition was so aggravated that 
he went home to New York to die ; — eighteen months 
later he was still living and there had been no re- 



OBJECTIVE SYMPTOMS. 129 

currence of pain or fever, with the exception of one 
somewhat similar attack which occurred some ten 
weeks after the second outbreak, while he was a patient 
of the Agnes Memorial Sanatorium. 



CHAPTER VIII. 
DIAGNOSIS. 

The diagnosis of laryngeal tuberculosis is simple in 
typical cases bnt in certain incipient lesions, atypical 
cases without constitutional or demonstrable pulmo- 
nary manifestations, and uncommon mixed types, 
syphilis or carcinoma and tuberculosis, it may be ex- 
ceedingly difficult and at times entirely impracticable. 

Primarily it must be understood that neither the 
tuberculous infiltrate nor ulcer has any absolutely dis- 
tinctive characteristics aside from the presence of mili- 
ary tubercles; certain types may be almost pathogno- 
monic, but atypical lesions of other diseases occasional- 
ly show the same peculiarities and invade the same 
structures. 

For example, pear shaped swellings of the arytenoids 
are usually considered pathognomonic of tuberculosis, 
yet a corresponding appearance is sometimes given by 
a unilateral gumma or bilateral edema in nephritis. 

The turban-shaped epiglottis may depend upon in- 
fectious edema or the perichondritis of syphilis, and 
uneven projections of the interarytenoid sulcus are 
occasionally caused by epithelioma, pachydermia, 

chronic catarrhal laryngitis and certain rare new 
growl hs. 



DIAGNOSIS. 131 

In considering the symptomatology it was shown 
that there is nothing distinctive in the color of the mu- 
cous membranes. 

Anemia is not characteristic as it occurs in only a 
small percentage of the cases, is usually a manifesta- 
tion of general anemia and occurs frequently in other- 
wise healthy individuals. 

The presence of local anemia should suggest the 
necessity of a thorough general examination, and it 
may thus lead to the discovery of an otherwise unsus- 
pected tuberculosis, but apart from this it has little 
diagnostic significance. 

When the tuberculous process is fairly well estab- 
lished the diagnosis is easily made even when the 
lungs are apparently normal. 

It is in the incipient stages that the chief difficulties 
are encountered. 

The most typical of the early lesions is infiltration of 
the interarytenoid sulcus, associated with, or inde- 
pendent of congestion of the vocal cords, and when 
found in a patient with pulmonary tuberculosis may 
be considered pathognomonic. 

When it occurs in an otherwise apparently normal 
individual, four conditions must be taken into consider- 
ation : — 

1. Simple catarrhal hypertrophy. 

2. New growths. 

3. Pachydermia. 

4. Syphilis. 

1. The thickening of simple acute or chronic catarrh 
is generally less extensive, does not show the same 
marked convexity during phonation, is less translucent 



132 LAKYNGEAL TUBERCULOSIS. 

in appearance and is usually smooth in contrast to the 
rougher and more uneven infiltrate of tuberculosis. 

Variations from the typical may occur in either con- 
dition, however, through which the types become simi- 
lar. 

In such instances cauterization will frequently clear 
the diagnosis for it produces prompt recession of the 
non-tuberculous exudates. 

2. New growths of the posterior wall are extremely 
rare and can only be differentiated from the fullness 
of tuberculosis by microscopic examination of the ex- 
cised tissue. 

3. When pachydermia is limited to the interary- 
tenoidal mucosa and shows irregular outgrowths, mi- 
croscopic examination alone can show the true nature 
of the process. 

4. Syphilitic infiiltration of the posterior wall may 
give a picture identical with that due to tuberculosis 
and the diagnosis must depend upon the history, the 
further course of the disease and the therapeutic test. 
It is extremely rare, however, for any of these diseases 
to be limited to the sulcus without associated lesions of 
other structures. 

CHRONIC CATARRHAL LARYNGITIS. 

Incipient tuberculous lesions, if limited to the vocal 
cords, bear a striking resemblance to the congestion of 
simple catarrh. 

A large percentage of phthisical patients show some 
evidence of catarrhal laryngitis and the question 
whcl her this hyperemia is simple 1 in nature or the re- 
sult of a submucous infiltrate is hard to answer. 



9 



DIAGNOSIS. 13.' 

The tuberculous variety rarely involves the entire 
larynx, or both sides to an equal degree, in contradis- 
tinction to catarhal laryngitis which is practically al- 
ways universal or symmetrical. 

Monochorditis, or an inflammation or thickening of 
one ventricular band or one-half the epiglottis, never 
occurs in the simple form and indicates tuberculosis, 
syphilis, a malignant growth or traumatism. 

If the unilateral hyperemia is associated with pul- 
monary phthisis, and particularly of the correspond- 
ing side, the diagnosis is clinched. 

The subjective symptoms may aid in determining 
the true condition, for when we have to deal with an 
early infiltrate the hoarseness and cough are usually 
more severe than when dependent upon simple inflam- 
mations, owing to the fact that the tuberculous infil- 
trate begins in the submucous tissues and is more ex- 
tensive than the changes resulting from simple catarrh. 

Early paralysis points to tuberculosis, for it has been 
shown that this symptom is a comparatively frequent 
phenomenon even before any laryngeal changes are 
evident. In this contingency early malignant diseases 
must also be given consideration, for paralysis or im- 
paired mobility is one of the most suggestive signs of 
carcinoma. 

Simple catarrh is responsive to treatment, hence an 
unduly intractable case, or one that frequently recurs 
without obvious cause, is suspicious. 

Superficial erosions are found in catarrhal laryngi- 
tis but true ulcers never occur. 



134 LAKYNGEAL TUBERCULOSIS. 

PACHYDEEMIA. 

Many cases of pachydermia closely resemble tuber- 
culosis, hence the differential diagnosis is often dif- 
ficult. 

In pachydermia involving the vocal processes the pic- 
ture is pathognomonic : upon one cord there is a broad- 
based circumscribed excrescence, upon the correspond- 
ing point of the oposite cord a depression into which 
the excrescence fits. (Plate X, Fig. 34). 

Tuberculosis shows no similar appearance. In some 
instances there is a groove formed in an infiltrated 
cord by pressure of the opposite one, or an apparent 
grooving along the free edge due to infiltration of both 
the superior and inferior surfaces without involve- 
ment of the free border, but the conditions are entirely 
different and the wider involvement in the tuberculous 
cases is distinctive. 

The only condition apparently similar is where 

one vocal process is deeply ulcerated, forming a tri- 
angular pouch, and the other shows circumscribed in- 
filtration at a corresponding point. 

Close inspection, however, shows the true condition 
and in pachydermia true ulceration does not occur. The 
voice, in tuberculous lesions of this nature, is marked- 
ly aphonic; in pachydermia it may be almost normal. 

In pachydermia the cords remain freely movable, 
in tuberculosis there is not infrequently impaired mo- 
bility or actual paralysis. 

SYPHILIS. 

Considerable import has been credited to the site 
of the lesion in the differentiation of syphilis and tu- 
berculosis. 



DIAGNOSIS. 135 

While each of the diseases has favored points of at- 
tack the exceptions are so numerous that they invali- 
date all diagnostic conclusions based solely upon the 
regions involved. 

Tuberculous ulcers of the epiglottis are usually lim- 
ited to the tip and laryngeal surface, while syphilis 
shows a marked predilection for the free edge and the 
lingual surface. 

Although ulceration limited to the lingual surface is 
highly suggestive of syphilis, tuberculosis rarely at- 
tacking this portion, it cannot therefore be inferred 
that limitation to the under surface and base implies 
tuberculosis. 

I have seen several cases of epiglottic tuberculosis 
in which the lesions occupied the lingual surface. 

Complete destruction of the epiglottis is unquestion- 
ably more common in syphilis than in phthisis, but as 
it does occasionally occur in the latter condition, inde- 
pendent of any other laryngeal focus, its diagnostic 
worth is almost nil. 

Both diseases produce hyperplasia of the inter-ary- 
tenoidal mucosa, and in both the lesions are sometimes 
limited to the vocal cords. 

Syphilis attacks the anterior half of the cord more 
frequently than tuberculosis but isolated ulcers due 
to the latter condition are occasionally seen about the 
anterior commissure. 

In arriving at a diagnosis, therefore, it is not ad- 
visable to give much weight to the site of the lesion. 

A single exception, perhaps, can be made in favor of 
those ulcers limited to the lingual surface of the epi- 



136 LARYNGEAL TUBERCULOSIS. 

glottis where the probabilities are all in favor of syphi- 
lis. 

Theoretically, the syphilitic and tuberculous ulcers 
have certain well marked characteristics, hut in prac- 
tice it is often impossible to distinguish between them. 

The ulcer of phthisis is essentially slow in develop- 
ment and occurs in tissues already considerably infil- 
trated, the margins are ill-defined, merge gradually 
into the surrounding parts, are wavy and "mouse 
eaten." If the ulcer is of the deep variety there will 
be some undermining of the edges. 

The edges and base show numerous granulations and 
are covered by a copious muco-purulent secretion. Scar 
tissue is rarely seen for there is slight tendency 
towards spontaneous healing, and the ulcer is usually 
superficial and has a decided grayish, soft appearance. 

The ulcer due to syphilis is of rapid development and 
is not preceded by chronic infiltration, although there 
is often considerable edema. It is clear cut, with 
edges sharply defined, elevated, undermined and prom- 
inent, and is usually deep from the outset. 

Surrounding it there is a vivid red or purplish are- 
ola and the base seldom shows any granulations. 
(Plate X, Fig. 35.) 

Scar tissue often exists in the immediate vicinity 
and the secretions are more tenacious but less copious 
than in tuberculosis. The syphilitic ulcer occasions 
much less pain than the tuberculous. 

The one absolutely pathognomonic sign is. the pres- 
ence about the tuberculous ulcer of the numerous 
small yellow nodules known as miliary tubercles but 
these are not always present or discernible. 



PLATE X. 

Fig. 34:. Pachydermia laryngis. 

Fig. 35. Syphilitic ulceration of the larynx. 

Fig. 36. Incipient epithelioma of the vocal cord. 



PLATE X. 

Fig. 34. Pachydermia laryngis. 

Fig. 35. Syphilitic ulceration of the larynx 

Fig. 36. Epithelioma of the vocal cord. 




Fig. 34. 




Fig. 35. 




Fig. 36. 



PLATE X. 



DIAGNOSIS. 137 

The character of the voice is of little assistance for 
while the syphilitic voice is raucous in contrast with the 
weak, suppressed voice of phthisis, so many variations 
occur in each as to destroy any value it might other- 
wise have. 

In all doubtful cases recourse must be had to pains- 
taking general and microscopic examination and the 
therapeutic test. 

In syphilis some other indications of the disease will 
nearly always be uncovered: ulcers or old scars or 
swellings of the testicles, penis, lymph glands, palate, 
pharynx, mouth or bones ; skin eruptions, or a history 
of habitual abortions, &c. 

In looking for old signs of syphilis the fact must not 
be overlooked that in a few well authenticated instances 
tuberculosis has produced palatal perforation and that 
when this has occurred the wound has born a strik- 
ing resemblance to that caused by syphilis. 

The same statement holds true in regard to the nasal 
septum; perforations of the quadrangular cartilage 
due to tuberculosis are not uncommon, and must be 
differentiated from simple perforating ulcers and 
those due to syphilis. 

The presence of pulmonary lesions will usually point 
to tuberculosis but the possibility of a laryngeal syph- 
ilis and pulmonary tuberculosis, or laryngeal tubercu- 
losis and syphilis of the lungs, must not be overlooked. 

Both diseases are occasionally present in the larynx 
at the same time. 

The therapeutic test will usually promptly clear the 
diagnosis but one element of doubt may arise within 
the first few weeks. It occasionally happens that even 



138 LAKYNGEAL TTJBEKCULOSIS. 

the tuberculous lesions will improve temporarily un- 
der such treatment, but it is always fleeting and the 
lesions promptly lose all they have gained. 

The same phenomenon is occasionally observed in 
malignant growths, due to temporary absorption of the 
surrounding inflammatory edema. 

In all doubtful cases examination should be made of 
portions of the involved tissues and of secretions from 
the ulcer, but even in typical tuberculous ulcers ex- 
amination may fail to demonstrate bacilli, tubercles or 
giant cells, for it is often impossible to remove more 
than the surface and hence a negative result is value- 
less. 

Bacilli are always present in the secretions of tuber- 
culous laryngeal ulcers and an attempt may be made 
to demonstrate them. 

The larynx should be thoroughly cleansed by anti- 
septic sprays and swabs, and the ulcer touched by a 
cotton-wound applicator. 

If tubercle bacilli are found it is practically diagnos- 
tic, although it must be admitted that, despite the care- 
ful local cleansing, they may have been deposited by 
the sputum. 

A diagnosis by means of tuberculin injections is 
often possible and is unattended by danger. 

If the local condition is tuberculous an increase in 
the hyperemia, with a marked rise of temperature 
within one to two hours, will usually follow the injec- 
tion of one milligram. Miliary tubercules sometimes 
appear over the infiltrated tissues. 

If no reaction occurs, a larger dose may be given 
after one or two days, and if still without result, a yet 



DIAGNOSIS. 139 

larger injection — 10 milligrams — after another two 
days. 

Tuberculosis can be almost definitely excluded if 
no reaction then occurs. 

PEOLAPSE OF THE VENTRICLE. 

Prolapse of the ventricle may be mistaken for tu- 
berculosis when the inferior part of the ventricle is 
infiltrated to such an extent that it partially overhangs 
the vocal cord. Firm pressure with a cotton-tipped ap- 
plicator will cause recession of the prolapse. 

LUPUS. 

Laryngeal lupus is almost always secondary to 
disease of the skin and neighboring mucous mem- 
branes and is then easily recognized. 

When the laryngeal deposit is primary it bears a 
strong resemblance to tuberculosis and might readily 
be mistaken for it. 

The nodules of lupus are extremely indolent and ul- 
cerate so slowly that one part cicatrizes while another 
is disintegrating; thus infiltration, ulceration and ci- 
catrization are found side by side. 

Lupus is extremely rare, runs an almost painless 
course and is frequently limited to the epiglottis. 

LEPROSY. 

Leprosy is never limited to the larynx and the skin 
condition is pathognomonic. 

Hoarseness and dyspnea are always present but 
dysphagia has not occurred in the few cases observed. 



140 LARYNGEAL TUBERCULOSIS. 

The epiglottis is usually thickened and edematous, 
ulceration may be absent or occur only late in the dis- 
ease, the mucous membrane is hyperemia and the tu- 
bercles, when present, appear as rounded nodules with 
a skin-like surface. The condition is extremely rare. 

CABCINOMA. 

Carcinoma in the pre-ulcerative stages, or in rarer 
instances where there is beginning ulceration of the 
diffuse infiltrative type, closely simulates tuberculosis. 

Particularly is this the case where the lungs are ap- 
parently normal and the individual past the meridian 
of life. 

If the growth is of the typical fungus variety or if 
marked ulceration or lymphatic involvement has oc- 
curred, no difficulty in differentiation is encountered, 
but if it appears as a smooth, diffuse infiltrate, micro- 
scopic examination alone will reveal the true nature. 

Carcinomatous growths of this type have been fre- 
quently observed and are usually situated in the ven- 
tricle or upon the ventricular bands, — a common site 
of the tuberculous infiltrate. It is rare, however, for 
the latter condition to be strictly isolated, there being 
practically always simultaneous involvement of the 
cords or interarytenoid incisure. 

The malignant growth, on the other hand, usually 
occurs in a larynx otherwise normal, except perhaps 
for a chronic laryngitis. 

Epithelioma of the vocal cords, in the still curative 
stages, is likewise of doubtful appearance and might 
occasionally be mistaken for phthisis. (Plate X, Fig. 
36.) 



DIAGNOSIS. 141 

On the cords it appears as a warty growth, as a dif- 
fuse infiltration or as a monochorditis. The warty 
form bears some resemblance to a tuberculoma but the 
iatter usually lacks the inflamed base of the malignant 
growth and is not so apt to cause impaired mobility. 

Ph. Shech reports a case in which one-half the larynx 
was removed because of a circumscribed, broad-based, 
warty excrescence upon the left cord that was appar- 
ently of a malignant nature. Examination of the ex- 
cised tumor proved it to be tuberculous. 

Neither of the other conditions, i. e., diffuse infiltra- 
tion or monochorditis, offers any distinctive signs. A 
dirty white opaque appearance is suggestive of malig- 
nancy and likewise an early loss of mobility of the 
involved cord. 

Too much importance should not be attached to this 
early paralysis, however, for while it undoubtedly oc- 
curs in nearly all cases of malignancy, it has been 
shown to be a comparatively frequent symptom of 
early tuberculosis as well. 

The subjective symptoms are similar in the two dis- 
eases. The character of the pain provoked is not dis- 
tinctive. De Santi (Malignant Disease of the Larynx, 
p. 36) claims that the radiating pains to the ear are 
very characteristic of malignancy in that they are not 
so frequently noted in other affections of the larynx. 

We have seen, however, in considering the subjective 
symptoms, that this aural pain is a frequent accompa- 
niment of tuberculous disease and is present in prac- 
tically all the dysphagic cases. 

The age of the individual is of little real service in 
differentiation. Milignancy is rare before the fortieth 



142 LAKYNGEAL TUBEKCULOSIS. 

year, yet in 588 cases, nine occurred between the tenth 
and twentieth years, thirty between 20 and 30 and fifty- 
eight beween 30 and 40. 

In 2542 cases of tuberculosis, 404 occurred in indi- 
viduals over 40 years of age. 

Thus, while tuberculosis is most common before 40 
and carcinoma after this age, the exceptions are so 
frequent as to destroy its worth except as a sugges- 
tive sign, for of the carcinomatous cases 16.5 per cent 
occurred in individuals under forty years of age and 
of the tuberculous, 15.8 per cent in those over forty. 

The absence or presence of glandular enlargement 
is not often of practical assistance. 

Krishaber's statement that "as long as the cancer 
remains intrinsic there is no cervical glandular en- 
largement; when it is extrinsic the glands are in- 
fected;" — has been well substantiated, but in a not 
inconsiderable percentage of tuberculous cases there 
is more or less extensive involvement of the cervical 
and sub-maxillary glands, occurring without relation to 
the extent or locale of the lesions. 

In all doubtful cases a considerable fragment should 
be excised, cutting well into the base, and examined 
microscopically for the characteristic features of both 
conditions. 



CHAPTER IX. 

PROGNOSIS. 

In tuberculosis a definite prognosis is seldom permis- 
sible and to the larynx this rule applies with even 
greater force than to the lungs. So many factors are 
to be considered aside from the extent and locale of 
the laryngeal process, i. e., pulmonic or other organic 
tuberculosis, occurrence of intercurrent diseases, con- 
stitutional idiosyncrasies and weaknesses, the social 
and financial status, the moral and physical fortitude, 
&c, that anything more than a tentative prognosis is 
equally unwise and unwarranted. 

A decade ago the advent of laryngeal tuberculosis 
was considered as rendering the prognosis invariably 
hopeless, while even to-day the view of a recent au- 
thority that i i occasionally a case recovers ; nearly all 
die," is almost universally accepted. That this is the 
commonly accepted dictum is shown by the following 
citations : 

"We can hardly hope to do much more than retard 
its progress, and thereby prolong for a few months the 
life of the patient." — Sajous. 

"The prognosis is always extremely grave, and it 
is not certain that any case recovers." — Sir Morell 
MacKenzie, 1880. 



144 LAKYNGEAL TUBERCULOSIS. 

"As to figures, we might quote from John N. Mac- 
Kenzie, who deduced the fact that in 100 cases death 
resulted in from twelve to eighteen months after the 
usual synrptonis showed themselves, and that in 6 per 
cent a fatal issue occurred within six months." 

"Bosworth gives forty-six months as the longest 
time, and three months as the shortest time, after pul- 
monary tuberculosis was complicated with laryngeal 
invasion, or to quote his summary : — 

"The average duration of life in an ordinary attack 
of pulmonary consumption is three years ; the average 
duration of life in an attack of pulmonary consump- 
tion complicated by laryngeal invasion is eighteen 
months." — Jonathan Wright, 1902. 

Dr. Ph. Schech (Handbnch der Laryngologie), in 
summarizing his views, says : 

"Nevertheless, as even M. Schmidt and Heryng, the 
most outspoken advocates of the curability of 
laryngeal phthisis, agree, the number of complete and 
lasting cures is very small. Generally there is a re- 
currence after a shorter or longer time, and this is 
usually severer and more widespread than the primary 
attack: or the lung process makes such progress that 
the fatal result will be hastened thereby." 

Dr. W. C. Phillip of New York, in 1906, said that he 
had never seen a case involving the vocal cords, the 
epiglottis, the false cords and the arytenoids, recover. 
In his opinion they are always fatal. 

"When extensive ulceration of the larynx is found, 
we may safely predict that the patient will not live 
more than eight or twelve weeks. A few cases die 
within six weeks of the beginning of the disease. It 



PKOGsrosis. 145 

is not the belief, as formerly, that all of these cases are 
fatal, for there is ample proof that a few recover. "We 
nearly always find accompanying pulmonary tubercu- 
losis and it is probably safe to say that where laryn- 
geal tuberculosis is so complicated, nine-tenths of the 
patients die." — Ingals, Diseases of the Chest, Throat 
and Nasal Cavities, p. 441. 

Dr. H. Bert Ellis, of Los Angeles, at the twelfth an- 
nual meeting of the American Laryngological, Rhino- 
logical and Otological Society, held in Kansas City, 
Missouri, June, 1906, said that when he sees a case of 
serious tuberculosis of the larynx with considerable in- 
filtration, he feels tolerably certain that the patient 
will die within six months to a year. He does not be- 
lieve in local treatment. 

Such pessimism is entirely unjustified for while 
this form of phthisis must always be looked upon as a 
most serious one, the disease may be cured in a consid- 
erable percentage and temporarily arrested in the ma- 
jority of all cases. 

In no other disease is a statistical report of so little 
value for we are dealing not with a process of stand- 
ard or even fairly equable conditions, but with one 
where each is a law unto itself ; yet when we contrast 
the percentage of recoveries quoted by Bosworth in 
1893 (less than 1 per cent) with those by such a con- 
servative authority as Solly, computed from cases 
treated in Colorado, it is seen that progress has been 
real and substantia] and that this present pessimism 
is illogical. 

Solly says : 

"Taking the results in laryngeal cases without con- 



146 LAKYNGEAL TUBEKCULOSIS. 

sidering the ultimate fate of the patient, there was 
permanent arrest of the disease in 64 per cent; tem- 
porary arrest in 5 per cent additional cases in which 
the tissue again broke down shortly before death. 
Looking at the ulcerated cases alone, 50 per cent heal- 
ed permanently, 10 per cent temporarily. ' ' 

Levy, in 1900, reported 26 deaths in 86 infiltrative 
cases. Of 60 ulcerative cases 37 grew worse or died, 
and of those without involvement of the epiglottis or 
aryepiglottic folds only 10 per cent died or failed to 
improve. 

Lake has compiled the following table : 

No', of Cases Cures Improved 

Heryng 200 20 

Schmidt 300 16 33 

Lake 329 48 

Total 829 84 33 

While the contrast between the results in Lake's 
tabulation, showing about 10 per cent of recoveries, 
and those of a decade ago is striking, it is not so re- 
markable as that between this 10 per cent and the ap- 
proximate 55 per cent of Solly and other Colorado 
observers. In the second edition of his work, Lake 
says : 

"In the first edition I recorded 48 cures out of 329 
cases, or 14.59 per cent; and from 1901 to 1903 in- 
clusive, I have to record, out of 211 cases, 44 cures, or 
20.S5 per cent, and 14.21 per cent much improved." 

Of the earlier reports the most favorable are those of 
M. Schmidt: 



PKOGNOSIS. 147 

Year Cases Healed Percentage 

1888 181 34 18.7% 

1889 179 30 16.5% 

1890 155 32 20.6% 

1891 195 36 18.4% 

1892 188 39 20.7% 

Total 898 171 18.99% 

He has classed as "healed" all those remaining well 
at the end of the year during which they received treat- 
ment. Upon this report he makes the following com- 
ments : 

"A goodly proportion remained well still longer, 
certain it is that the greater number relapsed the fol- 
lowing year." 

The majority of these cases were ambulatory and 
lived under unhygienic conditions and in an unfavor- 
able climate and easily relapsed into the old methods 
of living after a seeming recovery. The percentage of 
cures in such cases is naturally much less than among 
the better class of private and sanatorium patients. 

The word "arrest" instead of "cure" should be 
used in all the above tabulations for the ultimate 
fate of the pulmonic process is not considered. The 
great differences in the mortality as detailed in these 
reports, approximately 40 per cent, probably repre- 
sents in part the increased chances of improvement dur- 
ing residence in the favored climates, — Lake's, Her- 
yng's and Schmidt's patients being drawn from Lon- 
don, Berlin and Frankfort respectively, while Solly's, 
Levy's and a majority of the author's cases were ob- 
served in Colorado. 

This is due not so much to the direct effect of the 
favored climates upon the throat lesions as to the coin- 



148 LARYNGEAL TUBERCULOSIS. 

cident improvement of the pulmonic process, the ulti- 
mate sine qua non of prognosis. 

In connection with the statement regarding the ef- 
fects of the so-called favorable climates, it is interest- 
ing to note the observation of Thost to the effect that 
laryngeal tuberculosis is much rarer and less severe 
in the damp climate of Hamburg than in the drier, 
dustier atmosphere of Vienna. 

A conservative estimate to-day would place the per- 
centage of probable recoveries at between 50 and 60 
per cent, without taking into consideration the ulti- 
mate fate of the individual, i. e., the pulmonic process, 
and each year the outlook grows increasingly bright 
notwithstanding the fact that our armamentarium has 
few remedies of greater efficacy than it contained a 
decade ago. 

What is the explanation of this apparent paradox? 

It depends in large measure upon earlier recogni- 
tion of the incipient lesions, more universal utilization 
of the essentials of treatment, local and constitutional, 
and to an almost equal degree upon the mental attitude 
of the physician and patient. 

Convinced of its incurability the laryngologist form- 
erly treated throat tuberculosis in a perfunctory man- 
ner, striving after the single goal of euthanasia, while 
to-day, with deep appreciation of the necessity of con- 
stant vigilance and supervision with its common re- 
ward, his increased zeal and confidence bring infinitely 
greater success. 

Moreover, pulmonary tuberculosis is now much more 
widely recognized in its earlier stages, and suitable 
treatment, hygienic and climatic, is generally instituted 



PKOGNOSIS. 149 

while there is yet good hope of eventual cure. In con- 
sequence, the laryngeal complications are much rarer 
than formerly and more amenable to treatment when 
discovered. 

In considering the curability of the throat lesions, 
prime importance must be placed upon the degree of 
pulmonary involvement and the general condition and 
powers of resistance, for the outcome of the laryngeal 
process must always depend in large measure upon 
the general constitutional state. 

That the progress of the laryngeal disease is in 
keeping with that of the lungs is the common but not 
invariable rule. This interdependence from a prog- 
nostic standpoint is most clearly shown by study of the 
so-called primary cases (laryngeal without demon- 
strable or only slight pulmonary or other organic dis- 
ease), where practically all cases recover. 

With each step in the advancement of the lung lesion 
the arrest of the throat process becomes increasingly 
difficult. This is due equally to impaired resistance 
entailing lowered powers of reparation, and to the 
increased likelihood of reinfection through the medium 
of sputum, blood or lymph. 

With far advanced lesions of the lungs, in miliary 
tuberculosis and in those cases with persistent hyper- 
pyxeria little can be anticipated beyond temporary 
control, or in advanced cases, the partial relief of 
dyspnea and dysphagia, but this end justifies vigor- 
ous measures in all cases where such symptoms are 
to be apprehended. 

Even with a rapidly progressing pulmonary lesion 
where the end can be definitely prognosticated, arrest 



150 LAKYNGEAL TUBEKCULOSIS. 

or complete cure of the throat lesion may not infre- 
quently result. Per contra, steady disintegration of 
the laryngeal structures occasionally accompanies a 
cicatrizing or already healed lung. 

It has been frequently claimed that laryngeal im- 
provement never accompanies advancing pulmonic con- 
ditions, but such is entirely contrary to my experience. 
It is not alone common, but frequent. 

The laryngeal lesions associated with fibroid phthisis 
offer a much more favorable prognosis than those com- 
plicating the more acute forms, and the outlook is also 
more generally favorable in those who have accident- 
ally acquired the disease than in those with bad family 
and personal history. 

In general, it may be said that those symptoms which 
render doubtful the outcome of the constitutional 
malady bespeak the same doubt in so far as the throat 
is concerned. 



THE LOCALE OF THE LESION IN ITS PEOG- 
NOSTIC SIGNIFICANCE. 

The most serious and obstinate of all the lesions of 
laryngeal tuberculosis are those of the epiglottis. Ex- 
tensive ulceration or universal infiltration usually war- 
rants an unfavorable prognosis, although even the 
severest cases may occasionally recover, as is shown 
by the following statistics in which there 4 is a percent- 
ages of 11.95 in a nested cases, and an additional 31.54 
per cent in which there was temporary improvement : 



PKOGNOSIS. 151 

EPIGLOTTIS. 



Percentage of 
No. Im- Unim- Arrested 

Cases. Arrested proved. proved. Cases. 



Incipient 13 7 4 2 53.84 

Moderate 22 8 6 8 36.36 

Advanced 92 11 29 52 11.95 



Total 127 26 39 62 34.0 



o 



In 72 cases of epiglottic disease recorded by Lake, 
amount of involvement not given, eleven, or one in 
six and a half cases, died. 

Moderate involvement, either in the form of shallow 
ulcerations or circumscribed infiltrations, is more se- 
rious than extensive intrinsic disease. 

Owing to the intimate connection between the mu- 
cous membrane and the perichondrium, inflammation 
of the latter almost invariably ensues at an early date 
with resultant necrosis of the cartilage. In these cases 
there is usually severe and uncontrollable dysphagia, 
regurgitation and some dyspnea. 

Next in point of danger ranks general involvement 
of the arytenoids and aryteno-epigiottidean folds. 
These lesions, as well as those of the epiglottis with 
which they are often associated, are late manifesta- 
tions of the disease, originating, as a rule, when both 
the pulmonary and laryngeal infections are far ad- 
vanced and progressive. 

In consequence of this, as well as because they pro- 
voke lasting dysphagia, the prognosis is generally bad. 

Isolated ulceration or infiltration of the arytenoid 
cartilages is fairly responsive to treatment, but when 
the disease has spread to the aryteno-epigiottidean 
folds the outlook is much less promising. If at the 



152 LAKYNGEAL TUBERCULOSIS. 

same time there is epiglottidean involvement, there is 
extremely small chance of arrest. 











Percentage 


Region. No'. 




Im- 


Uni in- 


of Arrested 


Cases. 


Arrests. 


proved. 


proved. 


Cases. 


Epiglottis, Arytenoids and 










Aryteno-Epiglottidean 










Folds 73 


5 


22 


46 


6.8 % 


Arytenoids and Aryteno- 










Epiglottidean Folds ... 47 


12 


19 


16 


25.53% 


Arytenoids alone 150 


80 


44 


26 


53.33% 


Total 270 


97 


85 


88 





Destruction of the various cartilages is of grave 
significance, both because of the local conditions upon 
which the necrosis depends and because it is usually 
found in association with progressive pulmonary dis- 
ease or with general miliary tuberculosis. The aryte- 
noids, however, are sometimes subject to disintegra- 
tion and the separation of large sequestra without se- 
rious results. 

Circumscribed ulcerations and infiltrations of the 
interarytenoid incisure respond well to treatment. 
Superficial ulcerations of the ventricular bands and 
vocal cords heal in the majority of all cases, while even 
extensive disease of these segments, if the remaining 
tissues are uninvolved, can usually be conquered. 



Region. NO. 

Cases 

Isolated Lesions of Inter- 
arytenoid Sulcus 79 

Isolated Lesions of Vocal 
Cords 21 

Lesions of Ventricular 
Bands without serious 
disease of other parts. . . 9 

Total 109 



Arrests. 


Im- 
proved. 


Unim- 
proved. 


Percentage 

of Arrested 

Cases. 


51 


26 


2 


64.55% 


19 


2 





90.47% 


6 


3 





66.66% 


76 


31 


2 





PK0GN0SIS. 153 

The association of two or more of these processes 
naturally lessens the chance of improvement, and un- 
fortunately there are usually several distinct foci. 

Both the site and extent of the lesions must be 
considered in arriving at an estimate of the probable 
chances of recovery, and it is this factor which 
makes it difficult to draw any conclusions of definite 
worth from tabulated reports. 

In the entire series of cases reported, 506, there 
were 199 of definite arest, 39.32 per cent ; and 155 addi- 
tional cases, or 30.63 per cent, in which there was im- 
provement during the period of treatment. There re- 
main 398 cases not covered by this report, in which 
the lesions were of such character as to render definite 
classification impracticable. 

Classified in the two primary groups of "Infiltra- 
tive" and "Ulcerative" cases, we have the following: 

Percentage 
Type No. Cases Arrests of Arrests 

Infiltrative Cases 537 326 60.7 

Ulcerative Cases 367 194 52.8 

Total 904 520 56.75 

It is impossible to say what percentage of these 
arrested cases remain well, for after temporary cure 
the great majority disappear and are never seen 
or heard from again. It is certain that a not incon- 
siderable percentage relapse and that a large number 

perish from other tuberculous processes, but that en- 
during cures are frequent, even in those with advanced 
lesions, regardless of the eventual outcome of the pul- 
monic process, has been attested by a large number of 
cases in all sections of the world. 



154 LAKYNGEAL TUBERCULOSIS. 

THE VOICE. 

Long periods of partial or complete aphonia may be 
succeeded by normal tone production — normal not only 
in resonance but in sustained power as well. As a 
rule, however, the voice remains permanently rough 
and inflexible. 

The most promising cases are those in which the 
condition is due to functional causes, or to the early 
infiltrates and superficial ulcerations of the vocal cords 
and interarytenoid sulcus. 

Aphonia consequent upon recurrent paralysis or 
ankylosis of the crico-arytenoidal articulation is near- 
ly always permanent, although some cases due to the 
latter condition recover. 

Deep ulceration of the cords, causing considerable 
loss of tissue and the so-called "saw tooth" edge, 
generally produces permanent hoarseness but perfect 
restoration is sometimes attained even after wide- 
spread and seemingly permanent destruction. 

DYSPHAGIA. 

The minor degrees of dysphagia are generally amen- 
able to treatment but the more severe cases, due to 
extensive extrinsic lesions, are exceeding! y rebellious. 
In the great majority of such instances temporary pal- 
liation is the ultima thule of our endeavors. 

The development of dysphagia, in the vast majority 
of all cases, can be prevented by recognition and treat- 
ment of the incipent lesions. 

"When far advanced, medicinal treatment is mostly 
ineffectual and radical intralaryngeal surgical man- 
agement is required. 



PLATE XL 



Fig. 37. Case ending in spontaneous cure coincident with 
rapid progression of the pulmonic process. 

Fig. 38. Lesions resulting in spontaneous cure in a 
patient whose general condition was undergoing 
speedy improvement. 



PLATE XL 

Fig. 37. Case ending in spontaneous cure. 
Fig. 38. Case ending in spontaneous cure. 



Fig. 37. 




(yk\S><K L- L-.-V -osl 



Fig. 38. 



PLATE XI 



PKOGXOSIS. 155 

DYSPNEA. 

Dyspnea rarely advances to the point of threatened 
asphyxiation. It is usually of slow development and 
responds to medical and surgical treatment, so it is 
only in the exceptional cases that tracheotomy is nec- 
essitated. 

Massier (Archives Internationales cle Laryngolo- 
gie, xviii, No. 5, 1904) described a case of death from 
glottic spasm in a patient with slight laryngeal tuber- 
culosis; — and instances of sudden asphyxiation, due 
to bilateral abductor paraylsis, are recorded. I have 
already described such a case (pg. 91). 

MILIAEY TUBERCULOSIS. 

Miliary tuberclosis of the larynx is invariably fatal 
when a manifestation of general miliary tuberculosis. 
Localized miliary tubercles, on the other hand, while 
usually of grave significance, may occasionally 
cicatrize. 

PREGNANCY. 

The relationship between the larynx and female geni- 
talia is an intimate one. At puberty, during the period 
of "change of voice," the laryngeal mucosa is subject 
to attacks of congestion and similar hyperemic seiz- 
ures occur during menstruation, pregnancy, &c. 

Among normal individuals the influence of this 
physiologic process is especially evident in singers 
whose vocal organs are unduly sensitive to all such 
influences. 

Of pathologic conditions none are so susceptible to 
these same influences as tuberculosis. The swelling 



156 LARYNGEAL TUBERCULOSIS. 

and congestion are nsnally markedly increased during 
the menstrual periods while pregnancy almost invari- 
ably causes rapid and fatal destruction. Of fifteen 
personal cases reported by Kiittner, all but one of 
whom acquired the disease during pregnancy, all died 
before or within two months after delivery. 

G-odskesen has collected 46 additional cases, the re- 
sults of which may be summarized as follows : 

35 treated endolaryngeally. 

23 died during pregnancy or within two months after 
delivery or abortion. 

2 cases of tuberculous tumor; operated; successful 
delivery. 

8 other cases : successful delivery. 

2 other cases : lost sight of before term. 
11 cases treated extra-laryngeally. 

8 tracheotomies. 

3 died immediately after delivery or abortion. 
5 successfully delivered. 

3 cases by laryngofissure and tracheotomy. 

1, five months pregnant, recovered from operation 

and lost sight of. 
2 other cases: death. 
Resume of 25 cases complicating pregnancy, by Kiitt- 
ner {Annal. des Maladies de I 'Oreille et de Larynx, 
1901, XVII) : 

3, pulmonary tuberculosis before pregnancy. 
12, pulmonary lesions doubtful. 

1, laryngitis preceded conception. 

2, laryngitis appeared in 6th month. 

12, laryngitis appeared during first half of pregnancy. 



PBOGNOSIS. 157 

1 with an apical lesion, and one with laryngeal tuber- 
culosis, who had been free from symptoms 3 to 4 
years, died after delivery. 
None of the cases reached full term. 
4 reached the ninth month. 
8 reached the eighth month. 
3 reached the seventh month. 
Eight infants died within three weeks. 
Sokolowsky (Berliner Klinische Wochenschrift, July 
1904) records 71 cases of laryngeal tuberculosis com- 
plicated by pregnancy: 
14 cases, results unknown. 
56 died during or soon after confinement. 
1 lived eight years. 

One case seen by the author, in which both the moth- 
er and child survived, is recorded on pages 171 and 172. 

Nearly all the children born of such mothers die in 
early infancy. Few women with laryngeal tubercu- 
losis become pregnant owing to the severe anemia 
usually accompanying such conditions. 

It may be considered axiomatic that pregnancy pre- 
disposes to tuberculous laryngitis, and will practically 
always cause a recurrence in healed lesions and a 
lighting up of incipient or quiescent cases. 

That pregnant women with phthisis so frequently 
develop laryngeal complications is due to the concomi- 
tant increase of the constitutional malady, to the pre- 
viously considered relationship between the larynx and 
genitalia and to the general lessening of vitality, the 
anorexia, &c. The same causes explain the rapidity 
with which old lesions advance. 

If the laryngeal disease is far advanced the out- 



158 LAEYNGEAL TUBERCULOSIS. 

come is nearly always fatal ; if incipient, prompt abor- 
tion offers the only fair hope of recovery. If abortion 
be impossible, tracheotomy should be performed at the 
earliest possible moment. 

Successful Delivery- 
Cases Lost Sight of (After Operation) Died 

15 15 

35 2 10 . *23 

8 5 t 3 

3 1 t 2 

61 3 15 43 

*Endolaryngeal operations. 
tTracheotomy and Laryngofissure. 

Since the above was written, every reported case 
has been collected and tabulated by Kiittner. This 
table is appended. 



(See Table on Opposite Page.) 



SYPHILIS. 

Next to pregnancy syphilis is the gravest of compli- 
cating diseases. If the tuberculous condition is in its 
incipiency healing may result, but when the lesions are 
advanced, even if the syphilitic spots can be brought 
under control, the tuberculosis rapidly advances. Sev- 
eral observers report cases in which the syphilitic com- 
plication seemed to exert a favorable influence upon 
the tuberculosis. 



pa;a 






Ir -ITP ,-( rt 



SUTArj 



auir} 8XUOS 
1B%}V paiQ 



q^iiq aaji'v? 

A^oajip jo 

9aojaq paiQ 



SuiArj 



to 

S-t to 

-g >>M 

r^ © fa 



ajq-BJOABj 



<N 






«# 










i— I 










i-H 




~ 






-H 


fa 

'3 


iO 


I-( 


■"* r-H i-l CO -H i— llOCi <-H 

IN 


i— 1 -H 


IN CO 




(NO-i-t 
CO 


co»o t— I <-* 


. 


TjH 




1—1 


CO 






"t 


i—i 




T-l 
1— I 


















"* 



Oi 




l~- 


— c 




,£ 


— 


3S 


00 


a as 








-»-> ID 




K fa 


— 


eS a. 





3 S3 fa 

a ai^ 1 
Ph 



p^ia 



ajq^JOA'Bj 



0) o 

13 O 



p^a 



aiq'BJOA'Bj 



sasBQ 
papaooa^j 



CO 
















CO 


IN 




<N -H 








M 




COlO 


IN 


CO'-HNCOCM.-HCSai-H 


HHHNCCH 


^ 


NI^HH 

CO 


-<*CO -H-H 



pajjoda-jj 



,_•© COlO IN CO --H (N t)< N 1-1 OS OS -H 
.3 tN 



^r^^HC^CO-H -^ 



I i-H T)I^-HH 



pq 



M 

a 



Oi~ 



PQts 

s3 



">CD '.2 

■^£ s n3 
;„«fc 



ic 



•CO ■ 


Of) 


•N ■ 


<N 


fa 


fa 


55 • 


55 • 






CO . 


10 . 


O • 


• 


02 • 


i—i 



Ol ■ -C35 -c5 

1— I • -i—( ■ w 



c . a 

o t- o 

"43 -3 '-3 
S3 g S3 

3^ 3 



3 . 3 
O t- C 

S3 £ C3 

'3 «"S 

3> 3 

6 S 

C-6 3 3T3 3PQ 

5 a> 5 S <» 5 

O h OOh o • 
o 3 O O C «^3 



S3 O S3: 
3 > 



00 • 

Tf<CO 

.0 

COS 

»— < 

co" • 

2c 

tf M 

s3 5. 

C S3 
<U— ■ 

bc_: 

.PQ 

"3 . 

co^3 



o 

e 
>> 

fa 

d 






Oft 



S S S §■ m 

a) a) as 



M-HHHJ;^ ^ g g^x;^ 

33 r re32-Sa;a><x>s3O03. *_...-,-, 

>^^< S3 £Sph§PhPhSpw> £££eh> £ 



£0 



:si 

) ■ — I'K OS 

i co^-i 

;oo .""-S 

10 c_- 
; • -^ 



u 



c 



toco . . 

WtN.ii 3 
4i -^^ 






.SH 



^fa-3 



OEh 



fe- i ^ 



s s 



o^ 

s3^5 

1 - 0) 

0) ■+» 
!^3 « 
! M V 
■ c3 — 



c s3.23i aj 



s3 
M 

-r 



b£>V 



c 



S ^3 
O X 3 S- 



J2 

o . 
■ ir fc- 

(Uffl g 

0) <D 3 

PQtfoW 



1 - - 






<M 



^ to 

JJ-d o'S S^ 
<WttJ>JOffiJOPi 



?jpQ- 



3P-1C ^co^ 



N c t- ■ 

5j c. «> 

S3 C. 3^ 

u C 3 



sw 



3 
. S3 

gO be 

'-PQ-s 

S3 3 



.taqum^ 



|-H (NCO-* iO COt^OCOO-HCNCO-* K3(ONXO:C 



Bg 



.5 c 



c a- 



h — 
S31^ 



3 <r 
c - 

CO £ 

?3 



0) c 

a, — 



u ? be 



g a> ct 

•^ ^" — 

— 33 
S3 ^ C 

be > 
+J 3 03-3 
c >."-' <D 

g d >> c 

3 03 > > 



'3 


3 

a 


S3 


1 



V 


3 



s 


c 




■ 


a 




O 


43 


- 


ca 




= 


~- 



g ID <u 

■— 03 -w 

0) ^> 0—1 
■3-° fa O 

-3 o 3 

: ;*. c 

a s3 2 oj 

3 o o>fc 

DQ s3 

03 * J 

fa e^ « 

git 8 

O s3 £0 



- - 



^ S3 r- 



«s^ oj i 2 • ■ 

c £*r; c >.3s 



s3£ 



PKOGNOSIS. 159 

INFLUENCE OF AGE. 

Either extreme of age, infancy or old age, renders 
the outlook donbly serious though a few notable cases 
of recovery at each extreme have been observed. A 
case is recorded of a man of seventy-four in whom tu- 
berculous laryngitis developed and healed, 

PATHOLOGIC FINDINGS. 

An attempt has been made to judge of the severity 
of the process by the peculiar pathologic conditions 
present in the individual case. (Baumgarten-Heryng). 

Thus it is claimed that the severest type is that rep- 
resented by tissue composed of pure lymphoid-celled 
tubercles rich in bacilli; the most amenable, the 
epithelioid or giant cell tubercles with few bacilli, while 
those composed of lymphoid and epithelioid varieties 
occupy a medium position. 

Such deductions, according to my experience, are ab- 
solutely unreliable, no relation whatever existing be- 
tween the severity of the case and the type of the tissue 
existent, and in many cases the exact opposite obtains. 

Upon the most florid case within the author's remem- 
brance the following report was submitted by the 
pathologist, Dr. J. A. Wilder : 

"Sections from the tissue of the larynx, case of Mr. 
F., show the general changes of tuberculosis. 

"The tubercles show no evidence of caseation and 
consist chiefly of connective tissue cells and lymphoid 
cells with a moderate number of epithelioid and giant 
cells. Numerous sections stained for tubercular bacilli 



160 LARYNGEAL TUBERCULOSIS. 

show them to be present in very small numbers only. 
Three typical bacilli only were found after a prolonged 
search. ' ' 

SPONTANEOUS HEALING. 

While it may be stated, as a general rule, that healing 
occurs only when the pulmonary process improves or 
becomes quiescent, cases of spontaneous healing have 
been reported, not alone in quiescent cases but also in 
those suffering rapid disintegration. 

Schech reports a case of complete healing in a pa- 
tient with extensive laryngeal ulceration whose general 
condition was rapidly growing worse, and I have seen 
two such cases. 

The most striking of these was a man of twenty- 
seven years who presented marked ulceration of both 
cords and the interarytenoid sulcus, with exten- 
sive infiltration of the ventricular bands. (Plate 
XI, Fig. 37.) His general condition was so bad 
that he was advised to return to his home in 
the East, where he died seven months later. 
Shortly before death I had the privilege of 
examining his larynx and found it entirely 
healed. No treatment had been given other than a 
cleansing spray. 

The lesions in the second case consisted of infiltra- 
tion of both arytenoid cartilages, ulceration of the right 
cord and infiltration of the left ventricular band and 
sulcus. (Plate XT, Fig. 38.) 

Eisenbarth has reported a case of spontaneous cure 
of the laryngeal disease in a man with both pulmonary 
and intestinal tuberculosis. 



PLATE XII. 



Figs. 39-40-41. Case showing rapid recurrence of lesions 
that had been brought to a stage of virtual 
arrest. 



Fig. 39. August 4, '04. 
Fig. 40. December 7, '04. 
Fig. 41. February 1, '05. 



PLATE XII. 



Figs. 39-40-41. Case showing rapid recurrence of lesions 
that had been brought to a point of virtual arrest. 



flit 



Fig. 39. 




Figr. 40. 





Fig. 41. 



PLATE XII, 



PK0GN0SIS. 161 

Heryng reports 14 cases of spontaneous healing in 
2810 cases of laryngeal tuberculosis. 

The slighter involvements, infiltrations and conges- 
tions, and occasionally shallow ulcerations, frequently 
improve and rarely entirely recover coincident with 
the improvement of the general condition, but it is un- 
wise to forego local treatment because of this shadowy 
hope for nearly every case will steadily progress un- 
less energetically handled. 

BECUKKENCE. 

In conclusion, attention is directed to the fact that 
in speaking of the result, the words ' i healed ' ' and ' ' ar- 
rested" lesions have been advisedly employed. 

A cure cannot be claimed until a number of years, 
from two to five, have elapsed from the time of appar- 
ent arrest, and it cannot be gainsaid that these lasting 
cures are uncommon, owing to steady progression of 
the process in the lungs. 

After varying intervals recurrences are probable 
and are usually of severer type than the original in- 
fection. 

The recurrences are generally due to some insult 
to an incapsulated tubercle long quiescent, and could 
usually be avoided by a continuance, after an apparent 
cure, of those hygienic dietetic rules in force during 
the period of active treatment, but it is only the excep- 
tional person who can continue to hold out against the 
allurements of city life. If relapse occurs the prog- 
nosis is usually worse than in primary attacks. (Plate 
XII, 39, 40 and 41.) 

Laryngeal phthisis, when complicated by invasion 



162 LARYNGEAL TUBERCULOSIS. 

of tlie pharynx, runs a rapid course and death results 
usually in from a few weeks to one or two months. 

To two causes this universal fatality can be attrib- 
uted : pharyngeal involvement is a late manifestation, 
resulting, in the majority of cases, only when the lung 
and laryngeal conditions are far advanced and the 
general vitality completely sapped; to this the result- 
ant dysphagia rapidly adds and treatment proves ab- 
solutely ineffectual. 

Coincident involvement of one or both ears has no 
prognostic significance, for the aural suppuration ex- 
erts no appreciable influence upon the pulmonary or 
laryngeal disease, nor upon the general nutrition. 



CHAPTER X. 
BECORDS. 

Showing Possibilities of Treatment in Some Apparent- 
ly Hopeless Cases. 

A small number of case reports are appended, not 
because they are in any respect typical or indicative 
of the results usually to be attained, but because they 
offer a striking exemplification of the idea so frequent- 
ly reiterated throughout this work, i. e., the occasional 
curability of even the most advanced cases and the 
wisdom, therefore, of persistent treatment of every 
such patient, regardless of the extent, character and 
locale of the lesions. 

CASE I. 

W. P. GL, a man of twenty-six years, was first seen 
in June, 1903. He had come to Colorado in January of 
the same year, nearly twenty-four months after the 
recognized onset of his pulmonary symptoms, and had 
been advised because of his extensive pulmonary in- 
volvement, emaciation, high temperature and pulse, to 
at once return home. There was complete aphonia of 
thirteen months ' duration, and for eight weeks he had 
had severe dysphagia with slowly developing dyspnea. 

On examination of the larynx the following picture 



164 LAKYXGEAL TUBERCULOSIS. 

presented: enormous swelling of both arytenoids al- 
most closing the laryngeal aperture, which was still 
further encroached upon by the edematous aryteno- 
epiglottidean folds ; moderate infiltration and deep ul- 
ceration upon the laryngeal surface of the epiglottis; 
vocal cords almost completely hidden. (Plate XIII, 
Fig. 42.) 

No hope of permanent benefit was held, but for the 
relief of the dysphagia the affected part of the epiglot- 
tis was removed and ten days later both arytenoids 
were cut back as far as possible. Between operations 
and subsequently, daily applications of five per cent 
formalin were made. 

The operations resulted in complete relief of the 
dysphagia, and there was rapid improvement in the 
general health with an increase in weight of seventeen 
pounds within four weeks of the time of healing of 
the last operation wound. 

Laryngeal improvement was both rapid and continu- 
ous, and by February, 1905, twenty months from the 
time of first examination, he was pronounced cured 
both as to the lungs and larynx. At that time there 
had been no dysphagia for over a year and the voice 
was practically normal, both in volume and flexibility. 

There has been no relapse. 

CASE II. 

G. P., an accountant, was referred to me in April, 
11)05. He had lived in Colorado for fifteen years and 
had acquired pulmonary tuberculosis while serving in 
the army of the Philippines; 

The Lungs showed consolidation with moist rales on 



PLATE XIII. 



Fig. 42. Edema of the arytenoid cartilages and aryteno- 
epiglottidean folds. The epiglottis is thickened 
and ulcerated. (Case I.) 

Fig. 43. Massive infiltration and extensive ulceration of 
left ventricular band : bilateral arytenoidal ul- 
ceration and infiltration : ulceration of the right 
vocal cord and of the interarytenoid sulcus. 
(Case II.) 

Fig. 44. Ulceration and infiltration of both vocal cords, 
ragged infiltration of the posterior wall, and 
perichondritis of the left arytenoid. (Case III.) 



PLATE XIII. 

Fig. 42. Edema, of the arytenoid cartilages and aryteno- 
epi^lo^tidean folds. The epiglottis is thickened 
and ulcerated. 

Fig. 43. Massive infiltration and extensive ulceration of 
the left ventricular band : bilateral arytenoidal 
ulceration and infiltration : ulceration of the 
right vocal cord and of the interarytenoid sulcus. 

Fig. 44. Ulceration and infiltration of both vocal cords, 
ragged infiltration of the posterior wall, and peri- 
chondritis of the left arytenoid. 







Fig-. 42. 




Fig. 43. 




C^S,N^<N t_l— >-- Q<b1- 



Fig-. 44. 



PLATE XII 



ILLUSTKATIVE CASES. 165 

both sides down to the fourth rib. On the right side 
there was a cavity of large size. There was great 
emaciation, the pulse varied between 120 and 130, and 
the early morning temperature was usually about 100 
and from this ran up to 103 and 103 1-2 in the evenings. 

For three weeks there had been such severe dyspha- 
gia as to absolutely prohibit all eating; he had been 
able to drink in the Wolfenden position only. 

Aphonia had been complete for seven months. 

Laryngeal examination showed massive infiltration 
of the left ventricular band, completely hiding the cor- 
responding vocal cord. The entire band was studded 
with ulcerations. Both arytenoids were edematous 
and covered by numerous small ulcers. The right 
vocal cord was ulcerated deeply along the entire edge 
and the inter arytenoid sulcus was infiltrated and ul- 
cerated. (Plate XIII, Fig. 43.) 

Both arytenoid cartilages and the left ventricular 
band were thoroughly curetted and painted with pure 
lactic acid. Formalin, 5 per cent, was applied daily, 
followed by injections of orthoform emulsion, with 
surprising improvement as the case had been consid- 
ered hopeless. 

By the middle of the following month the dysphagia 
had disappeared, the temperature was normal and the 
general condition remarkably improved. 

By September first he was sufficiently well to go on 
a long camping trip, and now after two years there is 
no recurrence although he has suffered several se- 
vere attacks of acute laryngitis. 



166 LAKYNGEAL TUBERCULOSIS. 

CASE III. 

Mrs. S., aged 29, came to Colorado in August, 1904. 

There was incurable pulmonary involvement, con- 
solidation and moisture to the base on each side with 
an immense cavity on the left. 

In the larynx there was advanced infiltration with ul- 
ceration of the entire edge of each cord, ragged pro- 
jections of the interarytenoid sulcus and perichon- 
dritis of the left arytenoid cartilage. 

She was given formalin rubbings followed by intra- 
tracheal injections every two days. At the end of six 
months the laryngeal condition was entirely arrested, 
although the general process had grown steadily worse. 
She is still alive and the larynx shows no recurrence. 
(Plate XIII, Fig. 44.) 

CASE IV. 

E. J., a physician thirty-four years of age, was re- 
ferred to me in the fall of 1902. 

He had had some hoarseness for several months but 
no pain until a few days before, when sudden and se- 
vere dysphagia developed. The epiglottis was swollen 
to several times the normal thickness, both ventricular 
bands were infiltrated and the left arytenoid was ede- 
matous. Both vocal cords were slightly ulcerated along 
the free edges, but there was no fulness of the sulcus, 
accounting for the slight disturbance of phonation. 

The genera] condition was poor and the entire left 
lung was affected, with consolidation on the right ex- 
tending to the third rib. The usual treatment was in- 
stituted: daily frictions with formalin, intratracheal 



ILLUSTKATIVE CASES. 167 

injections and the use at home, every three hours, of 
a one-half per cent formalin spray. 

Within eight months there was complete arrest of 
the local process. (Plate XIV, Fig. 45.) 

case v. 

Mrs. E. N., aged thirty, came under observation in 
April, 1902. Both lungs were involved throughout, 
there was extreme anemia, the temperature ranged 
from 100 to 103 degrees, and she was obliged to do 
all of her housework, cooking, washing, etc. 

Two-thirds of the glottis was filled by a large ragged 
growth that originated from and filled the entire inter- 
arytenoid sulcus. Both arytenoids were slightly thick- 
ened and the anterior third of the right cord, the 
only part of the free edge that remained uncovered, 
was ulcerated. 

Three operations were performed upon this masss 
before it was entirely removed. Within four months 
the throat process was completely arrested and the 
voice normal. 

She died in June, 1904, twenty-two months after the 
throat had been pronounced cured, and there was never 
any recurrence although she was forced to constantly 
undergo the hardest kind of household drudgery. 
(Plate XIV, Fig. 46.) 

CASE VI. 

A physician, forty-seven years of age, was first seen 
in June, 1904, because of a complete loss of voice that 
had lasted for three months. 



168 LAEYNGEAL TUBERCULOSIS. 

He had had tuberculosis of the lungs for one year 
but there was only slight involvement at the left apex. 
In weight he was twenty pounds below normal. 

The entire larynx, with the exception of the epiglot- 
tis, was extensively diseased. There was perichon- 
dritis of the left arytenoid, and great infiltration of the 
corresponding ventricular band which showed a large 
erosion at the most prominent point. 

The right band was likewise infiltrated and ulcerated. 

Both vocal cords were ulcerated at their unconcealed 
posterior ends and there was an ulcerated infiltrate in 
the sulcus. 

Several extensive operations were performed, in- 
volving the partial removal of both ventricular bands, 
the left arytenoid cartilage and the interarytenoidal 
growth. 

After two weeks ulceration appeared in the stump of 
the arytenoid, but this cicatrized later under the con- 
tinued use of lactic acid and formalin. 

Fifteen months after the beginning of treatment the 
laryngeal condition was apparently arrested, but the 
patient passed from observation and has not been 
again seen. (Plate XIV, Fig. 47.) 

CASE VII. 

Tit is patient, a man thirty years of age, came to Colo- 
rado in the winter of 1 902. 

The laryngeal disease was so far advanced that it 
seemed almost useless to prescribe anything beyond 
cocain and morphin. At least one-third of the epiglot- 
tis was destroyed and the entire stump was covered by 
angry ulcers. 



PLATE XIV. 



Fig. 45. Infiltration of the epiglottis and both ventricular 
bands, with edema of the left arytenoid. Vocal 
cords ulcerated and thickened. (Case IV.) 

Fig. 46. Large warty tumor of the posterior wall; infil- 
tration of both arytenoids, and ulceration of the 
anterior end of the right vocal cord. (Case V.) 

Fig. 47. Perichondritis of the left arytenoid : infiltration 
and ulceration of the ventricular bands, and ul- 
ceration of the vocal cords and interarytenoid 
sulcus. (Case VI.) 



PLATE XIV. 



Fig. 45. Infiltration of the epiglottis and both ventricular 
bands, with edema of the left arytenoid. Vocal 
cords ulcerated and thickened. 

Fig. 46. Large warty tumor of the posterior wall : infil- 
tration of both arytenoids, and ulceration of the 
anterior end of the right vocal cord. 

Fig. 47. Perichondritis of the left arytenoid : infiltration 
and ulceration of the ventricular bands, and ulcer- 
ation of the vocal cords and interarytenoid sulcus. 




Fig. 45. 




V / 



Figr. 46. 




/o>.\^>o->L- 1— :v* — CD <sl 



Fig-. 47. 



PLATE XIV. 



ILLTJSTEATIVE CASES. 169 

Both ventricular bands were enormously infiltrated 
and deeply ulcerated, completely hiding the vocal 
cords. 

The right arytenoid was infiltrated and its entire 
apex was converted into a large ragged slough. The 
corresponding aryepiglottic fold was edematous. 

The pulmonary condition was not advanced, there 
was only slight involvement at each apex, and the gen- 
eral condition was surprisingly good considering the 
extensive laryngeal destruction and the severe dys- 
phagia. 

The stump of the epiglottis and the right arytenoid 
were at once removed, the remaining ulcers were curet- 
ted and the whole larynx painted with 10 per cent 
formalin. 

Throughout the ensuing year there was slow but 
steady improvement and by October, 1903, the follow- 
ing conditions presented : slight fullness of both ventri- 
cular bands, arytenoids normal except for a small 
amount of granulation tissue upon the inner surface of 
the right cartilage, both vocal cords ragged and thick- 
ened and the epiglottic stump entirely healed. 

By March, 1904, two years from the time he first 
came under treatment, the laryngeal process was en- 
tirely arrested and his voice was one of unusual purity 
and resonance. 

It remains so to this day and the pulmonary disease 
is likewise cured. (Plate XV, Fig. 48.) 

CASE VIII. 

Mrs. F., thirty years of age, had had aphonia for two 
years when I first saw her in December, 1903. 



170 LAKYNGEAL TUBEKCTJLOSIS. 

Both vocal cords were deeply ulcerated, giving the 
typical "saw tooth" appearance; the left ventricular 
band, which was also ulcerated, partially overhung 
the cord ; the glottis was one-fourth filled by an ulcerat- 
ed mass springing from the inter-arytenoid sulcus and 
the laryngeal surface of the epiglottis showed an ulcer 
about the size of the little finger nail. 

The general condition was extremely bad : consolida- 
tion of both lungs throughout with two cavities of con- 
siderable size upon the right; high temperature and 
pulse, and marked anemia. 

The epiglottic ulcer was lightly curetted and the 
formalin treatment instituted. 

By the following August the left cord was entirely 
well and smooth, the epiglottic ulcer and those upon 
the left ventricular band were gone and the inter-ary- 
tenoid space showed nothing more than moderate 
fullness. 

During all this time the general condition had grown 
steadily worse. When seen again, twelve months later, 
the larynx was in a state of arrest but it was evident 
that she could live but a few weeks at most. (Plate 
XV, Fig. 49.) 

CASE IX. 

H. C, a lawyer by profession, twenty-nine years of 
age, was referred to the author in December, 1901. 

He had bilateral pulmonary involvement; had 
dropped in weight from 164 to 130 pounds and was a 
constant user of alcohol. 

At the beginning o\' his laryngeal trouble, one year 
previous, there bad been severe dysphagia for several 
weeks, but after curetteinent of the larynx this bad 



PLATE XV. 



Fig. 48. Extensive destruction and ulceration of the 
epiglottis, massive infiltration and ulceration of 
the ventricular bands and right arytenoid cartil- 
age ; the corresponding aryepiglottic fold is ede- 
matous. (Case VII.) 

Fig. 49. ''Saw-tooth" cords : ulceration and infiltration 
of the left ventricular band : the sulcus is filled 
by an ulcerated infiltrate and there is a large, 
shallow ulcer on the lingual surface of the epi- 
glottis. (Case VIII.) 

Fig. 50. Infiltration of the cords, ventricular bands, 
sulcus and right arytenoid cartilage. The pro- 
cess in the cords and upon the posterior Avail has 
advanced to ulceration. (Case IX.) 



PLATE XV. 



Fig. 48. One-third the epiglottis destroyed by ulceration, 
numerous erosions of the stump, extensive infil- 
tration and ulceration of the ventricular bands 
and right arytenoid cartilage. The correspond- 
ing aryepiglottic fold is edematous. 

Fig. 49. "Saw-tooth" cords : ulceration and infiltration of 
the left ventricular band : the sulcus is filled by 
an ulcerated infiltrate and there is a large shal- 
low ulcer on the lingual surface of the epiglottis. 

Fig. 50. Infiltration of the cords, ventricular bands, sul- 
cus and right arytenoid cartilage. The process 
in the cords and upon the posterior wall has 
advanced to ulceration. 




Fig. 48. 




Fig. 49. 







Fig. 50. 



PLATE XV. 



ILLUSTKATIVE CASES. 171 

passed away and had never returned. Almost from the 
beginning there had been complete aphonia. Examina- 
tion showed a true tuberculous ulcer in the nose, in- 
volving the anterior-inferior edge of the quadrangular 
cartilage and the neighboring parts of the floor of the 
nose. 

There was ulceration and infiltration of both cords 
and- infiltration of both ventricular bands ; the right 
arytenoid cartilage was twice its normal size and the 
inter-arytenoid sulcus was filled with an ulcerated 
infiltrate. 

The epiglottis, which I understood to be the part that 
had been curetted, was entirely normal. 

Several months later he developed intestinal tuber- 
culosis, but despite this the improvement in the laryn- 
geal condition was uninterrupted and by July the 
throat process was arrested and the voice almost nor- 
mal. 

He lived until December, 1904, but there was no re- 
currence in the larynx. (Plate XV, Fig. 50.) 

case x. 

H. E. O'N., an electrical engineer twenty- four years 
of age, was referred by Dr. J. A. Wilder, in March, 
1901. 

There was only slight consolidation of the right up- 
per lobe and the general nutrition was first-class. 

He gave a history of having had slight hoarseness 
for one month and severe dysphagia for four days. The 
advent of pain had been preceded by a sharp chill and 
high fever. Before this the temperature had been nor- 
mal but it now ranged from 100 degrees to 101.5 de- 
grees. 



172 LAKYNGEAL TUBERCULOSIS. 

In the larynx the following conditions were found : 

Left arytenoid cartilage and the left ventricular band 
completely dotted with innumerable miliary tubercles ; 
slight ulceration of the posterior ends of both cords; 
small mass of granulation tissue upon the inner surface 
of the right arytenoid; the left arytenoid and band 
vividly congested. 

On the posterior pharyngeal wall, slightly above the 
tip of the epiglottis and in the median line, was a mass 
of similar tubercles covering an area as large as a half- 
dollar. Between the individual tubercles and for a 
considerable distance surrounding them the mucous 
membrane was a deep red in color and much swollen. 
The pain was severe and constant and the tubercles 
were exquisitely sensitive to touch. 

By the fifth of April, thirteen days, the tubercles had 
disappeared, there was no pain and the temperature 
was again normal. 

In the following September, while camping out in the 
mountains, he had a severe attack of ptomain poison- 
ing and this was followed by a second crop of miliary 
tubercles in the larynx, but this time the pharynx was 
not invaded. The eruption was limited to the arytenoid 
cartilages. 

Within a few days the tubercles over the right carti- 
lage ulcerated, but those on the left persisted a few 
days longer and then gradually disappeared. 

Some time later he was admitted to the Agnes Me- 
morial Sanatorium and while there he suffered a third 
attack, tliis lime will) general increase of both the pul- 
monary and chronic laryngeal process. Al the end of a 
year he wenl to Sullivan County, Now York, where I 



PLATE XVI. 



FiG. 51. The left arytenoid and ventricular band are 
vividly congested and dotted with numerous 
miliary tubercules : the posterior ends of the 
cords are ulcerated, and on the inner surface of 
the right arytenoid there is a small mass of 
granulation tissue. (Case X.) 

Fig. 52. Both arytenoid cartilages are thickened, with an 
extension of the edema to the right aryepiglottic 
fold. Ulcerations extend over the right fold, 
cartilage, cord and ventricular band. (Case XT.) 



PLATE XVI. 

Fig. 51. The left arytenoid and ventricular band are viv- 
idly congested and dotted with numerous miliary 

tubercles : the posterior ends of the cords are 
ulcerated, and on the inner surface of the right 
arytenoid there is a small mass of granulation 
tissue. 

Fig. 52. Both arytenoid cartilages are thickened, with an 
extension of the edema to the right aryepiglottic 
fold. Ulcerations extend over the right fold, car- 
tilage, cord and ventricular band. 




Fig. 51. 




AVALL.Y- Del 



Fig. 52. 



PLATE XVI. 



ILLTJSTKATIVE CASES. 173 

understand he is yet living in comparatively good 
health. (Plate XVI, Fig. 51.) 

CASE XI. 

Mrs. M., of Birmingham, Alabama, was referred by 
Dr. Holden, of the Agnes Memorial Sanatorium, in 
March, 1907. 

She was suffering from excruciating dysphagia that 
had been steadily increasing for nearly ten weeks. 

She had developed pulmonary tuberculosis over a 
year before, had become pregnant and was successfully 
delivered early in February. Three months before 
full term she became aphonic and developed a slight 
degree of dysphagia. 

At the time of examination, soon after her arrival in 
Denver, there was complete consolidation of the right 
lung with consolidation and moisture of the left uper 
lobe. There was moderate dyspnea, extreme emacia- 
tion and depression, and the temperature rarely fell 
below 103 degrees. It was impossible for her to swal- 
low anything else than thick fluids and these only with 
the greatest difficulty. 

Both arytenoids were infiltrated and the right was 
the seat of three deep ulcers that covered almost the 
entire body. The right aryepiglottic fold was edematous 
and there was a small ulcer upon the right fold near the 
arytenoid. Both vocal cords were ulcerated and there 
were two small erosions upon the right ventricular 
band. 

A bad prognosis was given and the case put under 
active treatment in the hope of at least partially con- 
trolling the dysphagia. Daily frictions of formalin, 3 



174 LARYNGEAL TUBERCULOSIS. 

to 10 per cent, were made, followed by the intra- 
tracheal injections of orthoform emulsion. A formalin 
spray was nsed every two honrs and cocain given ad 
libitum. Within five weeks all of the pain had disap- 
peared, the breathing was easy and the general condi- 
tion rapidly improving. 

The ulcerations of the ventricular band, arytenoid 
and ary-epiglottidean fold had entirely gone and the 
only one remaining was upon the vocal process of the 
left cord. 

The arytenoids were still greatly thickened but the 
mucous membrane covering them was almost normal 
in color. 

Regular treatment was stopped June 1st, nine weeks 
from the time of first examination, with the larynx in a 
state of virtual arrest. 

Somewhat later she entered the Agnes Memorial 
Sanatorium, where she has remained something over 
three months with constant betterment of the pulmo- 
nary condition. 

The laryngeal condition is still quiescent and de- 
mands no attention. (Plate XVI, Fig. 52.) 



CHAPTER XI. 

HYGIENIC-DIETETIC TREATMENT. 

Since laryngeal phthisis is practically always depen- 
dent npon preceding pulmonary disease, no treatment 
can be effective nnless it takes into consideration the 
constitutional as well as the local requirements. 

Isolated cases in which spontaneous arrest result 
do occur, and we occasionally have the opportunity of 
observing a favorable issue from local treatment in an 
individual with whom poverty and ignorance effectual- 
ly prevent the enforcement of even the basic rules of 
hygiene, but such exceptional cases cannot in any 
way invalidate the rule. 

As a general proposition it may be stated that the 
entire result hinges upon the financial status of the in- 
dividual, for all the resources of medical skill, and 
every climatic, hygienic and dietetic advantage must 
be utilized to the fullest degree. The patient should at 
the outset be made fully aware of the nature of the 
process and its gravity, for unless he appreciates the 
necessity for and probable duration of the new regimen, 
he will be unequal to the task of curtailing his pleas- 
ures and completely abandoning, for the time being, 
all hope of honor and emolument. That this is true 
of pulmonary phthisis is universally recognized and 
it must apply with even greater force to laryngeal tu- 



176 LARYNGEAL TUBERCULOSIS. 

berculosis. The chief factor in recovery is the degree 
of physiologic resistance inherent in the individual, 
and since the addition of a laryngeal focns doubles the 
drain, it makes essential an unusual effort towards 
conserving and increasing this vital force. 

CLIMATE. 

A suitable climate, while far from being the sine qua 
non of successful treatment, exerts a strongly bene- 
ficial influence upon the disease by reason of its re- 
markable power in arousing dormant energies and in 
stimulating metabolism. 

There has developed of late a marked and unhealth- 
ful tendency to decry the beneficial effects of selected 
climates and to uphold the theory of universal equal- 
ity ; in other words, it is maintained that it is fresh air 
alone and not the peculiar properties of any special 
atmosphere that is of value. 

This question was fully considered by the Commit- 
tee on Climate appointed by the National Association 
for the Study and Prevention of Tuberculosis, in 1905, 
and its report is quoted at length : 

"If we look for the causes of the tendency to doubt 
the value of climate they are to be found, first, in the 
unskillful use in the past of climate as a therapeutic 
measure; secondly, in the formerly widely spread be- 
lief in a mysterious specific influence of climate which 
led 1o a superstitious faith in its unaided powers and 
therefore to a neglect of those even more important 
matters, hygiene, diet, instruction and detailed super- 
vision; third, in the effect on the general profession 
of their recent and all too limited experience with out- 



HYGIENIC-DIETETIC TREATMENT. 177 

door treatment at home, which has caused them to go 
from the extreme of an undue hopelessness in the past 
to that of an equally unwise hopefulness that any case 
can be cured in any atmosphere by sleeping out on a 
porch and eating freely. 

To discuss here the various forms of climate is not 
within our province, but it should rather be our effort 
to point out what in general are the effects which in 
climates have a beneficial influence. These can be clas- 
sified in the order of their importance, as; 

First, abundance and bacteriological purity of the 
air; second, sunshine; third, coolness, or, in a certain 
number of cases, warmth ; fourth, dryness, or, in a few 
cases a moderate degree of humidity; fifth, altitude; 
sixth, wind; seventh, equalibility ; eighth, soil. 

' ' The bacterial and chemical condition of the air has 
been carefully studied and has been found to vary 
from a very high pollution in the streets in our large 
cities to an almost absolute purity in high mountains, 
open seas, deserts, and arctic regions, and is very low 
in country and mountain climates, especially where 
sparsely settled. 

''Becalling the powerful role of streptococcal and 
other mixed infections in pulmonary tuberculosis and 
their power of changing a simple tuberculosis with 
chronic advance into a destructive consumption, noting 
also the bad effects of dusty atmospheres in producing 
bronchial catarrh, and especially the rapid lessening 
of mixed infections and such catarrhs in the purer air 
of our mountain resorts, the importance of this factor 
does not need to be further dwelt upon. We would 
only here note that we believe it is chiefly due to rein- 



178 LAEYNGEAL TUBEKCULOSIS. 

fection of tlie diseased lung by pus organisms and its 
irritation by dust, to which is often due the relapse of 
some cases when they return to city life. 

"After pure air we would place sunshine and sun 
heat, whose effects are both direct and indirect. Di- 
rectly while its effects are evidently beneficial, they 
have never been completely analyzed and therefore will 
not be dwelt upon here. The indirect effects of sun- 
shine as seen in its powerful stimulation of the pa- 
tient's spirits is of great importance. 

"Dryness in most cases is a most important factor 
through its valuable anti-catarrhal effects, but when 
extreme, this influence may be reversed and there are 
not a few cases in which a moderate degree of humidity 
is more beneficial. Generally, low humidity with mod- 
erately low temperature has a tonic effect and is bene- 
ficial in irritated conditions of the respiratory mucous 
membranes, while low humidity with very low temper- 
atures, while stimulating, is apt to irritate the mucous 
membrane. Low relative humidity with high tempera- 
ture is generally debilitating. High relative humidity 
with moderate temperatures are soothing to the irri- 
tated mucous membranes, but high humidity combined 
with low temperature favors catarrh. On the whole, in 
pulmonary tuberculosis, low relative humidity with 
moderately low, or low, temperature is most generally 
suitable and the average tubercular patient always 
makes liis best gains in cold, dry weather, where such 
conditions prevail, but there are certain cases who do 
better with a high relative humidity and warm temper- 
ature. 

'Equalibility in older people or in the very feeble 



HYGIENIC-DIETETIC TKEATMENT. 179 

can be of great value, but is not as important as used 
to be supposed. In stronger cases variations in tem- 
perature stimulate the vital activities, hence, generally 
speaking, equalibility is not an important factor. 

"Wind, when the patient is directly subjected to it, 
is harmful, but when he is properly protected its puri- 
fying influence on the air, provided vegetation is suffi- 
cient to prevent dust storms, is beneficial. 

"Altitude. Most authorities are agreed that other 
-things being equal some degree of altitude owing to 
the great purity of the air and to its stimulating effect 
on the metabolism and appetite, etc., is most desirable, 
but it is not here our function to discuss the large 
question that this opens up. Enough to say that care 
should be used to choose an altitude to suit the pa- 
tient's degree of vitality and heart-power." 

This report has been quoted in full because it points 
out the necessity of climatic treatment in all curable 
cases of pulmonary tuberculosis, and because as a gen- 
eral proposition it may be advanced that the climatic 
conditions best suited for the pulmonary disease are 
most helpful for the concomitant laryngeal lesions, and 
as it has been proven that every pulmonary patient 
financially able should seek a new and more favorable 
climate from that in which the disease developed, it is 
therefore manifest that all cases of laryngeal tubercu- 
losis, not hopelessly incurable, should be sent to that 
locality best suited to the pulmonary and general con- 
dition. 

Above all else, the termination of a laryngeal lesion 
is dependent upon the progress of the general disease, 
hence any measures advisable in the latter condition 



180 LARYNGEAL TUBERCULOSIS. 

are suitable for the throat. A few exceptions are to be 
noted : 

A continuous out of door life despite the conditions 
of the weather is advisable in practically all cases of 
pulmonary tuberculosis and is, therefore, generally in- 
dicated in laryngeal cases, but where there are ad- 
vanced and painful lesions, the patient is more com- 
fortable in a perfectly lighted and ventilated room 
unless the weather is moderate and equable. 

If the lesions are acute and the larynx highly in- 
flamed, the atmosphere should be kept moist and fairly 
warm. 

No matter how advanced the condition, unless there 
is acute inflammation, the patient must be kept con- 
stantly in the open air except during periods of high 
winds, dust storms, extreme cold, and sudden varia- 
tions in temperature. 

Contrary to the generally accepted theory that laryn- 
geal patients do best in a moist, warm climate, it has 
been the author's experience that the exact opposite is 
true, especially with the still curable cases. 

In the late stages of the disease, when widespread 
ulcerations exist, the moist warm climates of the 
Southern coasts are more soothing than the dry and 
stimulating air of the uplands, but in such instances it 
is a question of euthanasia and not of cure. As long 
as there is the slightest prospect of either permanent 
or even temporary arrest, the patient should seek that 
locality most suitable for the pulmonary disease with- 
out considering the larynx itself, except thai lie should 
qoI be sent beyond the reach of skilled laryngological 
supervision, or into those arid sections where the lm- 



HYGIENIC-DIETETIC TEEATMENT. 181 

midity is extremely low and where, because of lack of 
vegetation, dust storms are of frequent occurrence. 

A strongly unfavorable prejudice exists regarding 
the influence of high altitudes upon laryngeal tuber- 
culosis but it can be easily demonstrated that this is 
entirely unwarranted ; we have only briefly to consider 
the percentage of arrested cases in the so-called fav- 
ored climes, in comparison with those reported from 
all other sections, to show that the higher altitudes not 
only render arrest or cure more probable but that they 
also confer a certain degree of immunity. 

Observers resident in the high altitudes report an 
approximate percentage of 60 in permanent arrests, 
as against an average of 15 per cent from all other sec- 
tions of the world. 

These more favorable results cannot be ascribed 
to a possibly average milder type of the disease or 
to a greater proportion of incipient cases, for the ex- 
act opposite is liable to obtain because of the fact that 
these favored areas have long been dumping grounds 
for the indigent consumptives of the entire country. 

Levy (N. Y. Med. Journal, Nov. 1, 1902) from a 
large series of cases, arrived at the following con- 
clusions : 

1. "In cases in which both the lung and throat le- 
sions develop in Colorado, the throat lesion manifests 
itself 48 weeks later than in those originating else- 
where. ' ' 

2. "In cases in which the lung lesions develop else- 
where and the throat lesions in Colorado, the throat 
lesion manifests itself 62.3 weeks later than in those 
originating elsewhere." 



J 82 LARYNGEAL TUBERCULOSIS. 

The author's cases give approximately the same re- 
sults. Ou the other hand, such authorities as Lake 
and Schech strongly advise against high altitudes, and 
the latter recommends a moist, dust free atmosphere, 
and particularly long sea voyages. 

Low humidity with moderately low temperature is 
best in the majority of throat cases, and as with the 
lungs, the greater degree of improvement is usually 
made during the cooler months. 

The conditions in Denver, where the larger 
part of the statistics employed in the chapter on Prog- 
nosis were gathered, can be seen from the following 
reports of the United States Weather Bureau. The 
average of the two years, 1904 and 1905, has been 
taken : 

Monthly Sunshine. 

July Aug. Sept. Oct. Nov. Dec. 

Per cent 65. 4 64. 70. 74. 76. 68. 

Jan. Feb. Mar. April May June 

Per cent 58. 64.5 45.5 53. 60. 67.5 

Monthly A. M. and P. M. Humidity. 

July Aug. Sept. Oct. Nov. Dec. 

6 a.m., degree 72. 69.5 65.5 72. 61. 59.5 

6 p.m., degree 41.5 41. 36.5 47.5 40.5 49. 

Jan. Feb. Mar. April May June 

6 a.m., degree 68. 68. 80.5 69. 74.5 69. 

6 p.m., degree 53. 45. 57.5 48. 44.5 37.5 

Monthly Precipitation. 

July Aug. Sept. Oct. Nov. Dec. 

Inches 1.84 0.63 1.13 1.35 0.04 0.20 

Jan. Feb. Mar. April Mai/ June 

Inches 0.58 0.20 2.47 4.31 2.05 2.06 

Monthly Wind MOVEMENT. 

July Aug. Sept. Oct. Nov. Dec. 

Miles 5254 5079 5172 5431 5426 5813 

Jan. Feb. Mar. April May June 

Miles 5452 5196 5598 5564 5439 5476 



HYGIENIC-DIETETIC TEEATMENT. 183 

The author has had several opportunities of study- 
ing these cases during periods of residence in compar- 
atively high altitudes, 6000 to 8000 feet, and never was 
there an appreciably unfavorable influence exerted 
upon the larynx, except in patients with advanced and 
incurable lesions of an ulcerative type. In these in- 
stances the dry and cold air caused some irritation and 
increased pain, as was proven by their partial amel- 
ioration upon going to sea level. 

This experience has been the same throughout the 
mountains of Colorado, New Mexico and Arizona, ex- 
cept in those localities where vegetation is very sparse, 
for in such places the almost constant presence of dust 
in the atmosphere caused considerable irritation. The 
warm, moist air of Southern California seemed to 
exert a singularly soothing influence upon cases with 
advanced ulceration. 

The open air treatment in any climate, if rigorously 
enforced, has a marked deterent effect upon the devel- 
opment of laryngeal tuberculosis. 

In commenting upon the statistics gathered from 
thirteen British sanatoria relative to the development 
of laryngeal phthisis during the open air treatment, 
Lake (Laryngeal Phthisis, Pg. 52) says: 

' ' From this table it will be seen that out of 1,979 pa- 
tients, who neither had laryngeal infection at the time 
of admission, nor were attacked within two weeks 
from that time, only 22 became infected during the en- 
suing four months, a proportion of 1 in 90. ' ' 

"While it has been impossible to get definite statis- 
tics from many of our American sanatoria, it is the 
almost unanimous opinion that tuberculous infection 



184 LABYNGEAL TUBEKCULOSIS. 

of the larynx rarely occurs in patients who have care- 
fully adhered to the out-of-door, rest regimen for a 
number of weeks. 

Whether the patient remains in the place where the 
disease was contracted or seeks a new climate, he 
should at the outset spend some months in a well con- 
ducted sanatorium. In no other way can he learn so 
readily and thoroughly the proper mode of living; 
knowing the correct rules is not usually sufficient, the 
habit must be firmly fixed. 

Particularly is this true in connection with complete 
vocal rest, as few patients will submit voluntarily to 
this necessary regulation, and hopeful results are not 
to be anticipated unless absolute and prolonged ab- 
stinence from speaking be enforced. 

DIET. 

The diet should conform to that indicated in pul- 
monary phthisis but when dysphagia supervenes cer- 
tain modifications become essential. 

Owing to the mechanical hindrance to deglutition 
and the resultant nasal regurgitation, and to the pro- 
nounced aversion to eating consequent upon the severe 
pain attending every effort at swallowing, both the 
quality and quantity of the food, as well as the method 
of taking it, demand careful regulation. 

The bulk must be reduced to a minimum while the 
nutritive value is maintained by the highest possible 
concentration, at the same time keeping the food bland 
and unirritating. It must not be too hot nor too cold; 
loo tlii]] nor loo solid; too sweet nor too sour, and all 
spices must bo omitted. Nothing that acts as a me- 



HYGIENIC-DIETETIC TKEATMENT. 185 

chanical, thermic or cliernical irritant should be used. 

Thus the problem of how to supply the proper nu- 
tritive values and at the same time tempt the appetite 
by a variety is exceedingly difficult, and only possible 
in the milder degrees of dysphagia. 

Thin liquids occasion more trouble than the more 
solid foods, hence substances of a semi-solid or thick 
fluid nature must be the main reliance. 

First of all and the basis of nearly all these foods, 
is milk. If the digestion is unimpaired it is best given 
in the form of cream, and preferably, in so far as the 
throat is concerned, in large doses at long intervals 
rather than in the ordinary manner of small amounts 
frequently repeated. 

This naturally puts a severe strain upon the diges- 
tive organs, but sipping is practically out of the ques- 
tion as in nearly all these cases fluids must be taken in 
large gulps. 

Various preparations of milk or cream whereby the 
consistency is increased and a variety offered, are 
available. Thus koumiss, junket, egg nog, and dry 
bread soaked in milk and squeezed dry before eating, 
are of occasional service. The following recipes have 
been used with good effect : 

NUTKITIOUS COFEEE. 

Dissolve a little isinglass in water, then put one- 
half ounce of freshly ground coffee into a sauce pan 
with one pint of new milk, which should be nearly 
boiling before the coffee is added. Boil for three min- 
utes, clear, add the isinglass and allow it to settle. Beat 
up an egg and pour the coffee mixture upon it. 



186 LARYNGEAL TUBERCULOSIS. 

CREAM LEMONADE. 

Beat up the white of one egg, add three teaspoonfuls 
of sugar and the juice of one lemon. Pour over one- 
half glass of cracked ice and add four ounces of cream. 

MILK PORRIDGE. 

Tie some flour in a bag and boil from four to 
five hours. Grate to a powder and mix into a smooth 
paste with cold water. To four ounces of milk add one 
pint of water and stir in the flour. Boil ten minutes, 
constantly stirring. 

A preparation that has been found to be both nutri- 
tious and easily swallowed can be made according to 
the following formula : 

Mix 2 heaping tablespoonfuls of Eskay's or some 
similar food with one-half pint of cool water and 
make a smooth, thin mixture ; then boil in a double 
boiler for forty minutes, cool, and add two eggs, pre- 
viously well beaten, and mix. If desirable, add a table- 
spoonful of Angelica, Tokay or Muscatel vVme. 

Nothing is swallowed with greater ease than oils, 
hence the preparation of Olive Oil and eggs, under 
the name of Egmol, prepared by Park, Davis & Co., is 
valuable. 

Nutritious soups and bouillons can be given the 
proper consistency by the addition of sago, tapioca, oat 
meal or gumbo. They should be served moderately 
cool and without pepper. 

Custards, jellies, and either wine or coffee gelatin, 
are grateful and may he easily swallowed by those with 
only moderate involvement. Even in the severest cases 



HYGIENIC-DIETETIC TKEATMENT, 187 

meat in the form of "Biftick a la Tartare" can occa- 
sionally be eaten. 

Two onnces of raw meat from which all the gristle 
and tendons have been removed, is finely minced and 
thoroughly mixed with the yolk of an egg. This is 
eaten cold, without seasoning, either alone or spread 
upon thin slices of buttered bread. 

Beef juice can be given at intervals. 

Calves' brains, butter, kefir and calves' foot jelly 
are likewise palatable and are eaten with comparative 
ease. 

Malt extract is nearly always well born and is some- 
times more easily swallowed than milk. 

In advanced cases of laryngitis thirst is always a 
distressing symptom because of the attendant pyrexia, 
copious, tenacious secretions and the small amount of 
liquids taken. The thinner the fluid the harder it is to 
swallow, hence water cannot be taken in satisfying 
quantities. Luke warm or cold coffee, chocolate and 
almond milk are agreeable substitutes and are more 
easily taken than water. 

Acid drinks would be indicated were it not for the 
severe pain they produce, but this effect is partially 
counteracted by their mixture with cream or milk in 
such a way as to avoid curdling. The cream lemonade 
is one of the best of these preparations ; the recipe for 
another follows: 

WHITE OF EGG LEMONADE. 

Take two lemons, the whites of two eggs, one pint 
of boiling water and sugar to taste. The lemons must 
be peeled twice, the yellow rind being utilized, while the 



188 



LARYNGEAL TUBERCULOSIS. 



white layer is thrown away. Place the sliced lemon 
and the yellow peal in a jug with two lumps of sugar, 
pour the boiling water on them and stir occasionally. 
"When cooled to about the ordinary temperature of tea, 
strain off the lemons. When the lemonade is in full 
agitation by whipping, add slowly the white of egg and 
continue whipping for two or three minutes. While 




Fig. 53. 

still warm, strain through muslin. Serve when cold. 

Small ice pellets slowly dissolved in the mouth af- 
ford temporary relief. 

Ice used in this way for half an hour before eating, 
or in the form of compresses about the throat, will 
slightly lessen the pain on swallowing. 



HYGIENIC-DIETETIC TKEATMENT. 



189 



METHODS OF EATING-. 

As before mentioned, fluids can be swallowed much 
more easily by ' ' gulping ' ' than by sipping. 

If regurgitation or severe pain can be avoided in no 
other way, the patient should lie prone upon a sofa 
with the head well beyond the edge and somewhat be- 




Fig. 54. 

low the level of the body, and suck the fluid through a 
long glass tube. (Fig. 53.) 

While this is often of service it fails in the ma- 
jority of cases. 

Deep pressure exerted upon the sides of the neck by 
the palms of the hands, pressing inward and forward 



j 90 LARYNGEAL TUBERCULOSIS. 

from behind, and lifting the larynx away from the 
pharynx, often assists degintion to a slight extent. 
(Fig." 54.) 

When all other methods have failed life may be 
prolonged by feeding through the stomach tube and 
by nutritive enemata. The former method is usually 
inadvisable in that it is distinctly repugnant to most 
patients, the passage of the tube is painful and it 
cannot prolong life more than a short time at most. 
There can be but two possible indications : temporary 
feeding after laryngeal operations and the occasional 
necessity of prolonging life to the utmost, but the 
practice of forcing nutrition in this way, when no 
hope of even temporary improvement is held, is gen- 
erally reprehensible. 

When the necessity of prolonging life does arise, 
as well as in the first few days succeeding radical 
operative procedures, nutritive enemata will meet all 
the requirements and occasion much less discomfort 
and repugnance. 

Any of the following standard preparations can 
be used: 

1. — Eggs, two to three; 20 per cent grape sugar, one-half cup; Red 
wine, one glass; starch, a thimbleful. — Ewald. 

2. — Milk, 250 grams; egg yolks, two; salt, a pinch; Red wine, des- 
sertspoonful; starch, dessertspoonful. — Boas. 

3. — Milk, 250 grams; starch, CO to 70 grams. — Leube. 

4. — Milk, 250 grams; Peptone, 60 grams. — 

5. Crush one pound of beef, add one pint. of cold 
water and allow to macerate three-quarters of an 
hour, Raise to the boiling point and boil two minutes. 
Give four ounces every Pour hours. Use tepid. 



HYGIENIC-DIETETIC TKEATMENT. 191 

TOBACCO AND ALCOHOL. 

All cases of laryngeal tuberculosis are better off 
without tobacco in any form, but if the amount of in- 
volvement is slight and the patient long addicted to 
its use, moderate smoking can do no particular harm, 
especially if a thoroughly cleansed pipe with a long 
stem be used in the open air. 

After the use of tobacco in any form the mouth and 
throat should be well washed with a mild antiseptic 
solution. 

If for any reason alcohol is indicated it should be 
given in the mildest forms and well diluted with 
water. 

The harmful effects of excessive indulgence in spir- 
its are as pronounced upon the laryngeal lesions as 
upon the constitutional malady and should be abso- 
lutely prohibited as a regular habit. 

VOICE EEST. 

The influence of complete vocal rest upon the course 
of the disease is not generally appreciated and can- 
not be exaggerated. If the lesions are incipient and 
not progressive, moderate use of the voice may be 
permitted, but all singing, reading aloud and pro- 
longed conversations must be strictly enjoined. 

If, on the other hand, the process is moderately ad- 
vanced and active, absolute rest is imperative if the 
best results are to be attained. 

All conversation should be carried on by writing 
and the finger manual, or in some cases by whisper- 
ing. In the latter case the whisper must be soft and 



192 LAKYNGEAL TUBEKCULOSIS. 

low, for a loud or forced whisper is as harmful as 
ordinary speech. 

Even in the incipient stages arrest will be more 
certain and prompt if absolute prohibition of speak- 
ing is enforced, and it is perhaps no exaggeration to 
say that this is the one most valuable agent in the 
management of these cases. 

NASAL AND PHARYNGEAL HYGIENE. 

In all cases of laryngeal tuberculosis the mucosa of 
the entire upper respiratory tract must be kept in 
as nearly a perfect condition as possible. 

Mouth breathing, permanent or intermittent, nasal 
suppuration, or naso-pharyngeal and pharyngeal ca- 
tarrh naturally exert an unfavorable influence upon 
both the laryngeal and general condition, and should 
therefore be corrected unless there is some potent 
contra-indi cation. The mere presence of a tubercu- 
lous lesion in the larynx does not make in- 
advisable the surgical correction of obstructive and 
suppurative conditions of the nose or pharynx, pro- 
viding the general nutrition is good, the temperature 
not high, and that there is no organic involvement 
other than the pulmonary. If the laryngitis is acute 
the correction of such morbid processes should be 
postponed for the time being, and any surgical inter- 
ference is inadvisable in cases of far advanced dis- 
ease, but in all cases where arrest of the laryngitis is 
possible the establishment of normal respiration is 
imperative. 

If an operation is indicated it should be the sim- 
plest consistent with thoroughness, even if the sub- 
sequent condition is not made ideal. 



HYGIENIC-DIETETIC TREATMENT. 193 

The object is not to make an anatomically perfect 
nose bnt a physiologically good one, and in the great 
majority of instances this can be accomplished by 
measures so simple as to cause little discomfort and 
drain upon the patient's strength. 

Thus, if occlusion is due to a moderately deflected 
septum, such operations as the submucous resection 
and those requiring the wearing of tubes for consid- 
erable periods, should give way to compensatory 
turbinectomies, the removal of spurs, etc. 

Hypertrophied tonsils, lingual glands, etc., must 
likewise be removed if they are accountable for any 
marked local or reflex trouble. 

Enlargement of the lingual glands is especially lia- 
ble to aggravate the laryngeal disease, because of the 
fact that in the vast majority of instances in which 
the glands are sufficiently enlarged to touch the free 
edge of the epiglottis, they provoke an almost inces- 
sant cough that is of itself enough to cause consid- 
erable irritation and congestion in the larynx. 

These glands are enlarged to some extent in almost 
all cases of tuberculosis, although not sufficiently, as 
a rule, to cause epiglottic pressure, and are them- 
selves frequently the site of tuberculous changes. 

Showing the frequency of this involvement we have 
the statistics collected by Freudenthal. He says, "At 
the City Home, where we have only advanced cases, 
33 patients were examined and only eight were found 
negative, i. e., without an enlarged tonsil. The other 
25 had all marked hypertrophies of the tonsillar tis- 
sues of that region. 

"At the Bedford Sanatorium 86 patients were ex- 



194 LARYNGEAL TUBERCULOSIS. 

amined (males and females), of which 59 were in the 
so-called first stage of pulmonary tuberculosis, 20 in 
the second stage, 5 in the third, and 2 unclassified. 
Of these 63 were found to have a markedly enlarged 
lingual tonsil, while of the rest — (23) — the majority 
showed some hypertrophy, those having normal con- 
ditions being the exceptions." 

In fifteen consumptives examined by Dmochowski, 
the lingual glands were tuberculous in nine. 

In conclusion we can sum up by saying that the 
entire upper respiratory tract must be put into the best 
possible condition for the same reason that the nor- 
mal functions of all organs must be maintained, if the 
general tuberculous process is to be conquered. 



CHAPTEE XII. 
MEDICINAL TREATMENT. 

The medicinal treatment is naturally considered 
under two heads : constitutional and local. 

1. Constitutional. 

It is not within the province of this work to con- 
sider the various so-called "specifics," suffice it to 
say that as yet none of these agents has shown an 
appreciably curative influence upon the larynx. 

Krause (Berliner Klin. Wochenschr., No. 42, 1902) 
claims to have observed a favorable action in tubercu 
lous laryngitis from the intravenous injection of 
sodium cinnamate, or hetol. Practically all other 
observers, however, have had negative results, and 
in the few cases that have come under my observa- 
tion no reaction whatever has been observable. 

Several experimenters, notably Pottenger, of Cali- 
fornia, have reported enthusiastically upon the fav- 
orable effects of tuberculin, and Von Ruck's watery 
extract. Pottenger says: 

"The preparation that I have used for the most 
part is the watery Extract of Tubercle Bacilli (Von 
Ruck's). The larynx is the ideal location for a lesion 
to be treated by tuberculin for the dosage can be 
controlled absolutely by the local reaction produced 



196 LAKYNGEAL TUBEKCULOSIS. 

The larynx should be watched daily, and the dosage 
should not be increased beyond that which is neces- 
sary to produce a slight local reaction; nor should a 
second injection be given until all reaction produced 
by the first has disappeared. 

"Tuberculin administered in this manner will cure 
many cases of tuberculous laryngitis. It will increase 
the chances of recovery from fifty to seventy-five per 
cent, and in many cases it will offer practically the 
only hope." 

Von Ruck himself claims remarkable curative 
powers for his preparation. Before the National As- 
sociation for the Prevention of Tuberculosis, he said: 

"As regards the treatment of these cases (laryn- 
geal) the great majority require no local measures 
whatever. Immunization with the watery extract is 
all that is essential, except in instances in which the 
disease has advanced to the stage of massive infiltra- 
tion and deep ulceration. In such cases palliative 
measures to relieve the distressing symptoms are of 
course indicated." 

On several occasions the author has selected a con- 
siderable number of these cases, typifying each stage 
of the disease, and has had them treated by tuber- 
culin, keeping the larynx under daily observation. In 
not a single instance was there any notable improve- 
ment, at least in excess of that which usually occurs 
in patients who are placed under the best of hygienic 
conditions, but without treatment other than enforced 
vocal rest, cleansing sprays, etc., and these measures 
were enforced in every case. 

The great majority of laryngologists have expe- 



MEDICINAL TREATMENT. 197 

rienced similar negative results, and for this reason 
tuberculin is seldom used at the present time except 
for diagnostic purposes. 

As with all innovations, the treatment by bacterial 
vaccines, controlled by the opsonic index, is now be- 
ing eulogized as a specific in laryngeal as well as 
in pulmonary phthisis, but as yet we have no sta- 
tistics that justify the claim and we are not war- 
ranted, at the present time, in considering the treat- 
ment as anything more than an adjuvant that may be 
of occasional service. 

General medication, with the view of exerting any 
direct effect upon the larynx, is useless, excepting 
in so far as two indications are to be met, i. e., the 
control of cough and the facilitation and lessening of 
expectoration. 

Both of these objects are important, for the diffi- 
culty of causing cicatrization in a broken down tis- 
sue subject to incessant irritation by coughing and 
the passage of tenacious and infectious secretions is 
easily appreciated, and while this applies especially 
• to lesions that are advanced and painful, it is also 
applicable to those of an incipient character. 

For the cough either heroin or codein should be 
given in doses sufficient to reduce it to a minimum. 

Lozenges containing menthol, orthoform, etc., are 
sometimes of considerable service in allaying cough 
due to laryngeal or pharyngeal irritation. 

When expectoration is excessive the internal use 
of creosote or guaiacol, preferably in the form of the 
carbonates, creosotal and duotal, is indicated. The 
former, in doses of five drops after meals, gradually 



1 98 LARYNGEAL TUBERCULOSIS. 

increased to thirty drops, and the latter in doses of 
0.2 to 0.5, three times daily, increased to 1 to 2 gm., 
sometimes have a marked effect in reducing the quan- 
tity of sputum, and in allaying cough. 

To facilitate expectoration hot drinks are especially 
useful. A spoonful of whiskey in a glass of hot milk, 
or ten to thirty drops of aromatic spirits of ammonia, 
with a pinch of salt and soda bicarbonate in a glass 
of hot water, may be used for this purpose. 

The choice of local treatment depends upon the 
extent of the pulmonary process, upon the vigor of 
the individual, and upon the extent, character and 
location of the laryngeal lesions. 

It would manifestly be irrational to apply the 
same principles of treatment to the patient with ad- 
vanced pulmonary disease, high fever, emaciation, 
etc., as to one with an incipient lesion, high vitality 
and normal temperature. In the former instance 
the aim is euthanasia if the patient is absolutely 
doomed, or palliation and curative treatment suffi- 
cient merely to hold the local lesions temporarily sta- 
tionary if there is yet some hope of arresting the lung 
disease; in the latter case vigorous and sustained 
curative treatment is indicated. 

The remedies are applied in the following ways: 



(2. 
(3. 
(4. 
(5. 
(6. 



Inhalations. 

Sprays. 

Insufflations. 

Pigments. 

Intratracheal injections. 

Submucous injections. 



MEDICINAL TKEATMENT. 199 

Before considering these different methods in de- 
tail, the fact should be emphasized that no drug, no 
matter how employed, has any specific action upon 
the disease and that therefore none of the appended 
agents can be considered directly curative in any 
sense; they act by maintaining asepsis to a certain 
degree, by relieving pain and cough, by stimulating 
sluggish ulcers and by promoting absorption and fib- 
rosis, and within these bounds only may they be 
looked upon as curative. 

So many " cures" have been proposed, so many 
agents recommended, that no serviceable purpose 
can be fulfilled by giving them all in detail, therefore 
only those substances will be considered which have 
proven of some service in the author's practice. 

INHALATIONS. 

Steam inhalations are of considerable use in allay- 
ing an associated catarrh, in cleansing erosions and 
in favoring expectoration. To a slight degree they 
promote temporary anesthesia. For the latter pur- 
pose the most active drug is anesthesin, which may 
be used, in one of the following mixtures : 

Anesthesini 5 drs.- 

Mentholi 3 drs. 

01. Oliv 4 fl. ozs. 

Or 

Anesthesini 45 grs. 

Sp. vini. rect 1% fl. ozs. 

Aq. destil 2 fl. ozs. 

Inhale for ten minutes. 

Either of these preparations will produce a very 
slight degree of anesthesia, sometimes lasting as long 



200 LAKYNGEAL TUBEKCULOSIS. 

as two or three hours. Orthoform may be substituted 
for the anesthesin in either of the mixtures. 

The inhalation of any one or more of the essential 
oils; pine, eucalyptus, peppermint, sandalwood, etc., 
or of Comp. Tincture of Benzoin, assists to some ex- 
tent in combatting the accompanying catarrhal con- 
ditions. After the use of any vapor the patient must 
remain indoors for at least a half hour, and the in- 
halations may be repeated as often as every two to 
five hours. 

SPBAYS. 

The chief advantage of the spray correctly used is 
the possibility, through its instrumentality, of keep- 
ing the larynx free of mucus and pus, an absolute 
essential of successful treatment. 

To maintain cleanliness it must be used every two 
to four hours and considerable practice is required 
before the solution can be made to thoroughly bathe 
the entire larynx. Any non-irritant antiseptic may 
be used, my preference being for formalin, two to 
three drops to the ounce of the following detergent 
solution : 

Sodii biboratis. 

Sodii bicarbonatis aa gr. x 

Acidi carbolici gtt. iii 

Glycerini 3ii 

Aquae destil. q. s. ad. fl Si 

Following the cleansing solution a camphor-men- 
thol spray in oil is of some service. 

In dysphagia, to keep the pain in subjection and 
to make deglutition possible, the spray is invaluable. 
( (Main, 1 to 5 per cent, according to the degree of 



MEDICINAL TKEATMENT. 20J 

involvement, is the mainstay, but its unpleasant after 
effects of dryness and seeming constriction often ren- 
der its use inadvisable. 

Alypin, 1 to 10 per cent, is a valuable substitute; 
its anesthetic properties are only slightly inferior 
to those of cocain, and while the taste is equally un- 
pleasant it is only in the exceptional case that it 
causes constitutional depression. 

The action of all the anesthetics is enhanced by 
occasional change from one to the other. 

INSUFFLATIONS. 

The insufflation of various powders is one of the 
oldest, and most ineffectual, of the methods of intro- 
ducing medicaments. By " auto-insufflation " it is 
possible for the patient to draw a considerable 
amount of powder into the larynx. One end of a 
straight glass tube some six inches long is pushed 
into the powder until a sufficient amount is forced 
into the bore, the opposite end is then passed well 
back into the mouth, the lips and nose are tightly 
closed, and a deep inspiration taken. 

The powder is drawn into the larynx and is re- 
tained for a considerable period, often many hours. 

Iodoform, the powder most universally used, is 
irritating, frequently produces a troublesome cough 
and is destructive to the appetite, so should rarely be 
employed. 

Orthoform and anesthesin, thoroughly dusted 
upon the ulcerated mucosa, produce some relief of 
pain, much more evanescent, however, in the author's 
experience, than is commonly reported. A lasting 



202 LARYNGEAL TUBERCULOSIS. 

anesthesia of from eighteen to thirty- six hours is 
said to be frequent, but according to my observations, 
three to four hours is an uncommonly long effect, and 
even during this short period the relief afforded is 
insignificant. In many cases they are entirely in- 
effectual. 

None of the powders affect intact membranes and 
as they are mostly non-poisonous they can be used in 
any quantities and as frequently as desired. The 
continued use of orthoform, however, seems to have a 
slight disintegrating effect upon the ulcers and should 
not be used over long periods. 

Morphin is not generally satisfactory because of 
its constitutional effects and unfavorable influence 
upon the pulmonary secretions. 

Thiocol, highly praised by Fasano (Arch. Internaz. 
di Med. et Chir., XVI., Napoli, 1900) has not seemed 
to do any particular good, and the same may be said 
of the various iodine compounds; iodol, aristol, and 
traumatol; of resorcin; chinosol, a quinin deriva- 
tive, and of amyloform, a combination of formalde- 
hyde and starch. 

Almost the sole sphere of the insufflation seems to 
be in the home use of the anesthetic powders, and 
even for this purpose their use should be greatly re- 
stricted, as the soothing inhalations and anesthetic 
sprays are more effective and do not produce the irri- 
tative cough that so often follows the introduction of 
dry powders. 

PIGMENTS. 

In so far as medicinal treatment is concerned, the 
one really effective procedure is the direct applica- 



MEDICINAL TREATMENT. 203 

tion of the various pigments. Both the methods of 
using and the drags to be employed demand careful 
consideration. 

After witnessing the manner of making applica- 
tions in vogue with a large number of laryngologists, 
particularly in tuberculous cases, the conclusion is 
irresistible that faulty technique is responsible for 
such a large percentage of innocuous effects. 

Even at the present time it is next to impossible 
to purchase an applicator that is of the slightest use 
in treating laryngeal lesions of a tuberculous nature. 
The ideal instrument must combine sufficient strength 
to permit of firm pressure and "scrubbing," with 




Fig. 55. 

enough elasticity to prevent the possibility of making 
surface abrasions ; it must at the same time be light 
in weight and large enough to handle with a firm 
grasp. (Fig. 55.) 

Those purchasable at the instrument dealer's are 
either of thin flexible wire of little resistance and 
strength, or of hard and rigid steel that cracks and 
breaks after slight use. 

With an instrument of proper size and flexibility, 
applications can be made with sufficient firmness to 



204 LAKYNGEAL TUBEKCULOSIS. 

force the pigment well into the tissues, a sine qua non 
of successful treatment. 

As well try to heal an old syphilitic ulcer of the leg 
by applying ointments without preliminary prepara- 
tion of the surface, as to affect a sluggish tuberculous 
ulcer or infiltrate by too gentle manipulation, yet 
almost all writers on tuberculosis warn against " act- 
ive interference'' with the lesions, be they acute or 
chronic. 

In the majority of instances applications should be 
made at frequent intervals employing solutions of 
moderate strength, rather than at longer periods with 
more powerful ones. 

Except when it is desirable to produce a strongly 
caustic action daily frictions are generally advisable. 
The object is to maintain a continuous effect without 
promoting undue reaction; if this occurs complete 
rest must be given for some days. 

It often requires a considerable nicety of judgment 
to determine the point beyond which reaction must 
not be allowed to progress. When we are dealing 
with a case of angry ulcerations attended with swell- 
ing and severe subjective manifestations, an increase 
in both the subjective and objective symptoms due to 
over zealous manipulation might easily be considered 
simple progression of the tuberculous condition and 
lead to even more active interference. 

The following case well illustrates this point: 

"Mr. P., salesman, thirty- four years of age, came 
under treatment for a moderately advanced tubercu- 
lous laryngitis. Both vocal cords were infiltrated and 
ulcerated along their free borders, there was consid- 



MEDICINAL TKEATMENT. 205 

erable swelling of the interarytenoid sulcus, and 
both ventricular bands were irregularly ulcerated and 
moderately thickened. For six weeks he was treated 
daily by vigorous applications of 5 to 10 per cent 
formalin, with constant increase in the subjective 
symptoms. Each seeming advance brought an in- 
crease in the vigor with which the treatment was pur- 
sued. 

"Upon the development of alarming dyspnea, 
tracheotomy was advised and the case referred to me 
for operation. The larynx was closed, except for a 
pin-point opening, by the angry ventricular bands, 
which were covered with minute ulcerations. The vocal 
cords were completely hidden and the arytenoids were 
edematous and deeply ulcerated. Operation was de- 
ferred, antiphlogistic treatment instituted, and in ten 
days the dysphagia and dyspnea had completely dis- 
appeared. The condition upon the subsidence of these 
acute symptoms corresponded largely with that re- 
corded at the primary examination, except that the 
ulcerations were slightly deeper and more extensive. 
Within six months after the renewal of the old treat- 
ment, upon a somewhat less vigorous scale, the larynx 
argyrol and nargol, phenol, para-mono-chlor-phenoi 
no recurrence." 

The pigments most commonly used are lactic acid, 
formalin, ichthyol, resorcin, guaiacol, pyoktanin, 
argyrol and nargol, phenol, para-mono-chlor-phenol 
and Iodine Vasogen. 

LACTIC ACID. 
Since the year 1885, when Krause (Milksaure g. 
Larynxtubercul. D. Med. Woch.) advanced the claims 



206 LARYNGEAL TUBERCULOSIS. 

of lactic acid as a curative agent, and demonstrated 
upon the cadaver the presence of healed tuberculous 
lesions where the acid had been used during life, it has 
held first place in treatment. In lesions of an ulcera- 
tive type it has but one equal, formalin, but unlike the 
latter it is valueless in cases with intact epithelium. 

In sensitive patients the primary application should 
be with a solution of not over 20 per cent strength, 
although a preparation as weak as this has but slight 
curative value. 

The concentration should be rapidly increased to the 
full pharmacopeia! strength. Considerable misap- 
prehension exists as to the required frequency of ap- 
plications, it being used in many instances as often as 
three times a week. 

Lactic acid exerts a cauterizing effect upon an 
abraded surface with the formation of a thin scab 
which, as a rule, is not thrown off for about seven or 
eight days and sometimes not until as late as the sec- 
ond or third week. Beneath this scab, in favorable 
cases, healthy granulations form and new epithelium 
extends from the edges of the ulcer with final trans- 
formation into scar tissue. Until the scab has sepa- 
rated additional applications are valueless. 

The pain attendant upon applications of lactic acid 
is due to the ulcerated areas for it has no effect upon 
normal tissue, hence these spots should be well 
anesthetized, both in order to prevent suffering and to 
permit careful manipulation under guidance, of the 
mirror. In no other way can the application be ef- 
fectively made. 

T<> act upon a non-ulcerative area the lesion must 



MEDICINAL TREATMENT. 207 

first be converted into an open wound by scarification, 
as was the practice some years ago, or the diluted acid 
must be thrown into the tissues by means of a syringe 
and needle. The introduction of more penetrating 
agents has rendered both of these procedures unneces- 
sary, although the latter method is still used to some 
extent. 

FORMALIN. 

Since the year 1897, formaldehyde has almost en- 
tirely supplanted lactic acid in the author's practice, 
both in the ulcerative and infiltrative types, with ever 
increasing satisfaction. 

While in no way a specific it is the nearest to the 
ideal of any drug we possess, in that it is effective in 
every type of lesion in a degree equal, if not superior 
to, any other agent. Upon ulcers it is as effective as 
lactic acid used in corresponding frequency and con- 
centration, and possesses the marked advantage of 
causing comparatively little reaction and no pain of 
any moment. It is, therefore, possible and advisable 
to apply it daily, or at the least thrice weekly, in a 
strength varying from 3 to 10 per cent. 

In a number of almost parallel cases, one-half 
treated with lactic acid and one-half with formalin, as 
well as in a considerable number of individuals treated 
alternately with the two drugs, the formalin almost in- 
variably gave the better and more prompt results. 

A typical case from these records, demonstrated by 
the author at the 1904 meeting of the American Acad- 
emy of Ophthalmology and Oto-Laryngology, is quoted 
from the Laryngoscope, of October, 1904 : 



208 LAKYNGEAL TUBEECULOSIS. 

"Mr. W. M., jeweler, 32 years of age. In January, 
1902, six months after pnlmonary tuberculosis was 
diagnosed, there developed complete aphonia with con- 
siderable dysphagia and two months later, upon his 
arrival in Denver, he presented the following picture : 

"Entire epiglottis deeply ulcerated with loss of 
nearly one-half its substance ; ventricular bands so in- 
filtrated as to partially overlap the cords, with ulcera- 
tion at the most prominent point of each. The left 
arytenoid twice the normal in size and extensively ul- 
cerated. Both cords infiltrated and ulcerated through- 
out with considerable masses of granulation tissue 
at their posterior attachments. The interarytenoid 
sulcus infiltrated and ulcerated. 

"Treatment, of which formalin constituted the most 
important part, was instituted with considerable im- 
provement at the end of three months. At this time 
lactic acid was substituted, with the occasional use of 
guaiacol, with continued retrogression, when at the end 
of eight weeks the use of formalin was resumed. By 
the following January the ulcerations were healed ex- 
cept for one small spot on the under surface of the 
epiglottis, while the infiltration of the ventricular 
bands had almost disappeared. 

' ' At this time I left the city for four months and the 
patient was under the care of an experienced colleague, 
who having no faith in this treatment used lactic acid 
and methylene blue. Upon my return the throat was 
worse than at the first examinatioTi and a hopeless 
prognosis was again made. Under the old treatment, 
however, the condition rapidly improved, and six 
months later he accepted a position as a salesman in 



MEDICINAL TKEATMENT. 209 

a large jewelry store which lie lias since uninterrupt- 
edly held. 

' ' In examining the larynx to-day, were it not for the 
distorted epiglottis and slight scarring at several 
points, one could have no suspicion that it had ever 
been the seat of tuber culo si s." 

Formalin, in a strength of from 3 to 5 per cent, can 
be used daily, thus maintaining a continuous influ- 
ence, an effect impossible of attainment with lactic 
acid, and to this continued action, I believe, can be 
credited much of its really remarkable power. 

In lesions of an infiltrative and vegetative type for- 
malin is more generally effective than any other pig- 
ment, although in certain cases one of the other drugs 
may be more useful. 

When vegetations and infiltrations are localized or 
excessive they should be surgically removed, provid- 
ing the general conditions are favorable, but after all 
the tissue capable of surgical treatment has been dealt 
with, or primarily in case operative procedures are 
contra indicated, the frequent use of formalin is gen- 
erally advisable. 

This favorable action is likewise shown by its effect 
upon aural granulations, whether tuberculous or sim- 
ple inflammatory. 

The continued use of formalin is said to favor the 
development of dry gangrene, a result never seen by 
the author nor by any of his immediate colleagues. As 
a prophylactic agent it is unexcelled and its constant 
use in a one-half per cent solution, in the patient's 
hands, will save many a suspicious case from infection 
and many an incipient one from further development. 



210 LAKYNGEAL TUBEKCULOSIS. 

It is strongly antiseptic in weak solutions. In a 
strength of 1 to 10,000 it prevents the development of 
bacteria and it is germicidal in a 1 to 75,000 solution. 

A 1 -to 10,000 solution arrests the growth of the 
germs of anthrax, cholera, typhoid, and the staphylo- 
coccus pyogenes aureus. 

Its advantages may be summed up as follows : 

(1) It surpasses all other bactericides in solutions 
of a strength which can be tolerated. 

, (2) In tuberculous ulcers it is fully the equal of, 
and probably superior to lactic acid. 

(3). Its effect upon vegetations* is prompt and pro- 
nounced. 

(4) In infiltrative cases it is by far the most satis- 
factory remedy. 

(5) It is the only drug of the curative class that 
can with safety be placed in the hands of the patient, 
thus making it possible to maintain a continuous 
cleansing, germicidal and absorbent action. 

(6) Its field of usefulness comprises all the varied 
types of the disease. 

Tllie formalin solutions should be freshly made every 
two or three days, and the applications of the stronger 
solutions should be preceded by cocain, as they occa- 
sion sharp pain for several minutes, both laryngeal 
and aural. 

ICHTHYOL AND EESORCIN. 

Ichthyol and Eesorcin, 10 to 20 per cent, have been 
used to a considerable degree in non-ulcerative lesions 
of moderate extent, with fairly satisfactory results. 



MEDICINAL TKEATMENT. 211 

GUAIACOL AND CEEOSOTE. 

Guaiacol and Creosote, recommended especially by 
Chappell, Vacher, and Sendziak, are nsed in strengths 
ranging from 1 to 10 per cent. In the author's hands 
they have not proven satisfactory. 

PYOKTANIN. 

Pyoktanin, used upon ulcers, either in concentrated 
solutions or fused upon wire, is sometimes beneficial, 
although greatly inferior to lactic acid, formalin, and 
the phenol compounds. It can be used as an antisep- 
tic spray in 1 per cent solution, and has been strongly 
endorsed by Sheinmann, Schech (Handbuch Der 
Laryngologie, 1898) and Eosenberg (Behandl. d. 
Kehlkopftubercul. Ther. Monatsch. 7-9, 1888.). 

NAEGOL, AEGYEOL AND PEOTAEGOL. 

These organic silver salts, 1 to 20 per cent, are of 
considerable service in the so-called "pre-tuberculous 
stage,'' that is, where there is chronic congestion and 
relaxation of the mucous membranes without definite 
tuberculous changes. They exert no appreciable influ- 
ence when ulcerations have developed, nor in cases 
with marked tumefaction. 

PAEA-MONO-CHLOE-PHENOL. 

Para-mono-chlor-phenol is of use in both the ulcera- 
tive and infiltrative lesions. It is caustic in action 
when used as strong as 10 to 20 per cent. Simanowski 
(Ueb. d. Behandl. Phthisis u. anderer Erkrank. d. ob. 
Luftwege, m. Ortho-u. Para Chlor Phenol. Centralbl. 



212 LAKYNGEAL TUBEKCULOSIS. 

/. Lar. XI, 1895) prefers it to all other caustics and it 
is also well recommended by Hedderich, Seifert, Zinn, 
Spengler and Richards. 

IODINE-VASOGEN. 

Iodine- Vasogen, a 10 per cent preparation of iodine 
dissolved in vasogen, is of some service in cases of 
beginning infiltration, and in painful swellings about 
the arytenoidal joints. The vasogen is more penetrat- 
ing than the other media and the preparation is en- 
tirely painless. 




Fig. 56. 

Of all these remedies, those that have proven most 
effective in the author's practice and stand out pre- 
eminent, are formalin, lactic acid, ichthyol and iodine- 
vasogen. 

INTRATRACHEAL INJECTIONS. 

One of the most satisfactory methods of introducing 
medicaments into the larynx and trachea is by means 
of the intratracheal syringe. (Fig, 56.) 

Originally introduced for the cure of pulmonary 
tuberculosis, it lias to-day taken its rightful place as an 



MEDICINAL TKEATMENT. 213 

invaluable addition to the armamentarium of the 
laryngologist. 

Under direct illumination the point of the syringe 
is carried well down between the vocal cords and the 
injection is made while the patient takes a deep inspi- 
ration. The solutions, in considerable quantities, pene- 
trate into the larger tubes and minute amounts reach 
the remote alveoli. There is rarely any spasm, at least 
in excess of that occasionally produced by the simple 
laryngeal spray. 

As a rule the cough is markedly decreased, and the 
sputum is lessened in quantity and becomes less tena- 
cious ; the oily covering of the larynx protects it to a 
considerable extent against the irritant secretions, and 
the sensation of tickling in the throat and supra- 
sternal notch is often removed for many hours. 

The treatment is both curative and palliative. If 
topical applications are made at the same sitting the 
injection should be given last. 

Any of the following solutions may be used : 

1.— Menthol 30 gr. 

Guaiacol 10 gr. 

01. Sassafras 

01. Cubebs aa gtt. iii 

Glyniol 1 oz. 

2. — Camphor-menthol x to 60 grs. 

Olive Oil 1 oz. 

3. — Guaiacol 9 parts 

Bucalyptol 2 parts 

Menthol 1 part 

Saturated sol. of Iodoform in ether to 100 parts 

4. — Olei thymi, Olei eucalypti, Olei cinnamonii. aa gtt. lxxx 

Iodoform 15 grs. 

Olei olivae steril 3 iii 

Both of the following preparations are especially 
valuable in dysphagic cases. 



214 LARYNGEAL TUBERCULOSIS. 

5. — Menthol *1 part 

Almond oil 30 parts 

Yolk of egg 25 parts 

Orthoform 12 parts 

Water to f 100 parts 

6.— Menthol 1 dr. 

Anesthesin 5 drs. 

01. oil 4 fl. ozs. 

♦Increasing to 15 parts. 
fFreudenthal. 

All of the solutions should be used warm, between 
80 and 90 degrees F., and from 14 to 1 ounce can be 
injected at a sitting. 

When successfully made a feeling of warmth extends 
through the entire chest and when any of the pungent 
drugs are used they are frequently tasted, after cough- 
ing, from twelve to twenty-four hours. A second 
injection may be given as soon as the good effects of 
the preceding one have worn off, daily, or even twice 
daily if possible. 

SUBMUCOUS INJECTIONS. 

» 

The use of sub-mucous injections for the cure of 
non-ulcerative infiltrations of the larynx was intro- 
duced by George Major in 1886 (The Treatment of 
Laryngeal Tuberculosis by Submucous Injections of 
Lactic Acid, Canadian Med. and Surg. Journal, Dec. 
1886). 

In the following year the method was indorsed by 
both Heryng and Krause. In this country Chappell 
has been the leading advocate, and in England, Wat- 
son "Williams. 

A special syringe (Fig. 57.) is used and a few drops 
of the selected solution are thrown into the tissues at 
those points where the submucous tissue is most 



MEDICINAL TKEATMENT. 215 

abundant. The needle is introduced about one-half 
centimeter and the injections are made at intervals of 
not less than eight to ten days. 

The different experimenters have used different 
agents; Major, Heryng, Krause and Gleitsmann use 
from 3 to 5 drops of a 10 per cent solution of lactic 
acid ; Watson Williams, guaiacol, or 2 per cent aristol 
in almond oil, or perch] oride of mercury, 1 in 1,000 of 
glycerine and water; Stork employed a sublimate 
solution ; Lake a 20 grain to the ounce solution of chlo- 
ride of zinc, and Chappell, 1 to 4 minims of creosote- 




Fig. 57. 

or guaiacol in oil. Solly (Laryngoscope, June, 1904) 
advised the use of 20 minims of a 15 per cent solution 
of lactic acid. 

The following formula has been employed by Chap- 
pell : 

Creosoti 3i-ii 

01. gaultheriae 3iii 

01. ricini 3iii 

Paraffini liquidi 3i 

Menthol x grs. 

All of these substances when injected into the tissues 
produce severe pain and inflammation, with the forma- 
tion in many cases, of large superficial sloughs. Be- 



216 LAKYNGEAL TUBERCULOSIS. 

cause of this tiiey should always be used iu localities 
rich in submucous tissue. 

The results are rarely satisfactory, the reaction is 
too severe and better methods are available, hence the 
treatment has fallen into some disrepute and is not 
used as freely as a decade ago. The author has used 
lactic acid and guaiacol to some extent, but sometime 
since abandoned both as highly unsatisfactory. 

The daily use of the penetrating pigments, especially 
formalin, supplemented by the frequent spraying with 
the formalin-detergent solution, has been much more 
effective than the submucous injections, is painless, 
and has no harmful consequences. In case of extreme 
infiltration the removal of tissue by the cutting forceps 
is by far the preferable procedure. 

PHOTO-RADIO-THERAPY. 

Ever since Roentgen's discovery of the X-ray, con- 
tinued efforts have been made to cure laryngeal tuber- 
culosis by this and other rays with, it cannot be denied, 
only indifferent results. 

A voluminous literature has accumulated, a perusal 
of which forces the belief that while certain rays may 
in some cases favorably influence pain, cough and ex- 
pectoration, they exert little or no visible effect upon 
the diseased tissues. 

The Finsen light, high frequency current, Minin 
light, search light, sun light and radium have all been 
used to a certain extent. 

THE X-RAY. 

In the author's experience the Roentgen rays 
have proven almost invariably disappointing. When 



MEDICINAL TKEATMENT. 217 

employed upon incipient lesions no effect whatever 
has been observable, while in the advanced cases, 
those associated with ulceration and marked infiltra- 
tion or edema, the reaction has often been sufficient 
to provoke new activity with increase in both the sub- 
jective and objective symptoms. Unless carried to 
the point where some reaction was observable, no ap- 
parent influence was exerted. 

The majority of experimenters have had similar 
experiences and as a result its use has been largely 
abandoned by laryngologists, even by those who were 
in the beginning most enthusiastic. 

Pancoast (Phila. Med. Society, April 26, 1905) re- 
ported one case of at least temporary cure. This pa- 
tient had ulceration of the epiglottis and a tuberculoma 
of the anterior commissure, with consolidation and 
softening of the right apex. 

Applications of the X-ray, of ^ve minutes ' duration, 
using a medium vacuum tube having a resistance of 
about 3 inches of spark gap, with the anode placed 12 
inches from the patient, were made during a period of 
seven months. At this time the pulmonary lesion could 
scarcely be located and Dr. Harland reported the 
larynx cured. Pancoast also reports several addi- 
tional cases in which marked retrograde metamorpho- 
sis occurred. 

The rays to be effective must be used externally, for 
Roentgen himself showed that they cannot be polar- 
ized, deflected nor concentrated by lenses, hence it is 
not possible to deflect them into the larynx by means 
of a laryngeal mirror. 



218 LAKYNGEAL TUBERCULOSIS. 

The Finsen light and Minin light have even less in- 
fluence than the X-rays and therefore do not demand 
separate consideration. 

BADIUM. 

Theoretically, radium should be the most prac- 
tical radio-active substance for use in laryngeal 
phthisis, in that the rays can be brought into direct 
contact with the diseased tissues; they travel in 
straight lines and cannot be deflected except by a 
magnet. It is too early as yet, however, to draw defi- 
nite conclusions concerning its efficacy, although in 
the few cases to which it has been applied the results 
were negative. 

J. C. Beck (Trans. Anier. Academy Ophth. and Oto- 
Laryng. 1904) reported one case of laryngeal tubercu- 
losis with dysphagia in which radium alone failed to 
give any relief, but combined with other treatment 
seemed more effective than when local medical treat- 
ment alone was used. 

In a case of primary tuberculosis of the nasal sep- 
tum, accompanied by severe pain in the frontal region 
and some difficulty in breathing, he applied the radium 
33 times, in the beginning every day, then three times 
a week and finally once a week. He says : 

"The headaches and pain disappeared after the sec- 
ond treatment. After about six treatments the mass 
looked better and did not bleed as easily on touch. After 
twelve treatments the patient was able to breathe bet- 
ter, but far from free, and from this time on, until three 
weeks ago, which terminated the thirty-third treat- 
ment, the improvement as to diminution in size of the 



MEDICINAL TKEATMENT. 219 

growth lias not been perceptible. The appearance of 
the mass was improved. It appeared harder and looked 
as though the mucons membrane was going to cover 
it. Later treatment by the X-ray failed to induce fur- 
ther improvement." 

The technique is simple : 50 milligrams of radium of 
the 10,000 radio-activity, placed in a tube, is brought 
into contact with the diseased tissues and allowed to 
remain from live to thirty minutes. 

SUNLIGHT AND AEC LIGHT. 

The searchlight and the direct or reflected sun rays 
have been used with occasional good effect in so far as 
the relief of pain and some lessening of cough are con- 
cerned. 

Freudenthal, who has had a wide experience with 
the electric light, summarized his views (New York 
Med. Journal, July 12, 1902) as follows: 

"I can see in the electric light only an adjuvant that 
is of great assistance in the management of some cases 
of tuberculosis." 

During a period of nearly two years the author used 
the concentrated electric light rays in a large number 
of cases and finally abandoned the treatment as prac- 
tically valueless. That it had a favorable influence 
upon pain cannot be denied, and occasionally the cough 
was somewhat lessened and expectoration favored, but 
aside from these effects it seemed to be entirely with- 
out action and it has been possible to obtain these 
results in higher degree by other and much less fa- 
tiguing treatment. 

The sunlight treatment has been highly recom- 



220 LARYNGEAL TUBERCULOSIS. 

mended by Sorgo of the Alland Sanatorium, who 
claims to have seen essential improvement in all of 
14 cases so treated. His patients sit with their backs 
to the snn and the light is reflected into the larynx from 
a mirror mounted on a stand. With a laryngoscope in 
position, the patient controls the reflection of the rays 
by the image he obtains of the larynx. Sorgo says : 

"The results have surpassed all expectations. Es- 
sential improvement was obtained in every case. The 
best results were apparent in tumor-like infiltration of 
the laryngeal mucosa, while diffuse red infiltrations of 
the vocal cords yielded more slowly. The difference 
between the response of these two forms was most 
marked when both co-existed in the throat. The spe- 
cific action of the sunlight was particularly apparent 
in two cases in which the patients, from lack of skill, 
failed to expose more than a certain part of the vocal 
cords. The exposed area showed marked improve- 
ment, while a sharp line divided the improved, exposed 
area from the unexposed unimproved part. 

"The moral effect of this sunlight treatment on the 
patients is good. They see the infiltration subsiding, 
and, although the voice may still be hoarse, yet they 
know they are improving. They soon acquired the 
knack of this autolaryngoscopy. The number of ex- 
posures ranged from 6 to 44, during from two to six 
months." 

Autolaryngoscopy, to the extent of a patient direct- 
ing his own treatment and noting the improvement 
therefrom, does not appeal to the experienced laryn- 
gologist as a practical procedure and hence one is not 
inclined to give much weight to these statistics. 



MEDICINAL TBEATMENT. 221 

"When the sunlight treatment first gained prominence 
and was almost universally employed, both in the form 
of direct rays and by reflection from large concave 
violet mirrors, the author saw a considerable number 
of laryngeal patients who were receiving daily expos- 
ures of from thirty minutes to two hours. In not a 
single instance was there the slightest change in the ap- 
pearance of the involved tissues ; in several there was 
some lessening of dysphagia but not to as great an 
extent as was later observed from applications of the 
concentrated rays of the arc light. 



CHAPTEE XIII. 

SUEGICAL TREATMENT. 

ENDOLARYNGEAL OPERATIONS. 

Since the year 1880, when Moritz Schmidt first advo- 
cated the employment of deep incisions for painful 
swellings of the epiglottis and posterior wall, the ques- 
tion of surgical intervention in tuberculous laryngitis 
has been subject to endless controversy, with the de- 
cision, in so far as the great majority of laryngolo- 
gists is concerned, still in abeyance. 

The ultra enthusiastic hopes engendered by the com- 
munications of Krause and Heryng have not been ful- 
filled, but on the other hand, the extreme pessimism in- 
cident to the non-realization of these early anticipa- 
tions has given way to a moderate optimism, based 
upon the accumulated experiences of twenty years. 

The indications and contraindications for operative 
interference are of infinitely greater importance than 
the method of operating itself. In deciding upon the 
advisability of surgical intervention two indications 
must be kept constantly in view; the relief of pain, and 
the cure or temporary arrest of the disease. 

If the former indication alone is to be met, no con- 
sideration whatever need be paid to the general con- 
dition of the patient aside from his ability to with- 



ENDOLAKYNGEAL OPEKATIONS. 223 

stand the shock of the operation. We are confronted 
by a single problem and that concerns the probable 
degree of relief to be anticipated. 

It may be definitely stated that in general radical 
extirpation or division of the involved tissues will 
produce more or less complete relief of dysphagia, 
more lasting and effective than it is possible to obtain 
from any other system of treatment. 

Medicinal treatment is generally ineffectual in the 
severer cases of dysphagia and accomplishes little be- 
yond momentary control, and in consequence, any pro- 
cedure that offers promise of even partial relief must 
be considered a boon and this we undoubtedly possess 
in some one or more of the various radical operations. 
Even though the requisite operations shortened life 
they would still be indicated, but in practice they are 
found to prolong it and remarkable cures occasionally 
result even in apparently hopeless cases. 

If cure or arrest of the local disease is still probable, 
a number of conditions must be taken into considera- 
tion unless the surgical interference is to consist of 
nothing more than simple curettage of sluggish ulcers, 
indolent granulations, or small and sharply circum- 
scribed infiltrations. 

The following rules are generally applicable : 

(1) The lesions must be surgically incipient, that 
is, they must be accessible and fairly well circum- 
scribed. 

Only a localized lesion can be thoroughly eradicated 
and complete removal is advisable although not in- 
variably essential. It is not always possible to judge 
accurately of the boundaries of a seemingly localized 



224 LAKYNGEAL TUBEKCULOSIS. 

lesion, for the infiltration usually extends much farther 
than is evidenced by the laryngeal image, and an ap- 
proximately correct estimate is possible only to one 
with considerable clinical and pathological experience. 

Widespread infiltrations and ulcerations associated 
with high temperature and dyspnea are absolute con- 
traindications, but the rule cannot be held as applying 
to those advanced cases that have resisted all other 
treatment. 

(2) The lesion must be accessible. 

Occasional barriers to thorough endolaryngeal 
curettement are found in such conditions as a narrow 
and distorted larynx; a rigid or laterally compressed 
epiglottis; an unfavorable location of the lesion, and 
excessive reflex irritability, uncontrollable by cocain, 
where every effort at manipulation is provocative of 
violent attacks of retching and coughing. 

(3) The pulmonary process must be either incipient 
or quiescent. 

The condition of the lungs merits even more consid- 
eration than the extent and character of the local lesion 
itself. Advanced pulmonary disease or a less exten- 
sive condition that is rapidly progressive usually 
renders surgical work of any kind inadvisable but the 
statement made in connection with the surgically incip- 
ient lesions may be here repeated; none of these indi- 
cations and contraindications can be held as valid 
when the lesions have already proven resistant to 
other treatment, or when they are the cause of severe 
and otherwise unconquerable pain. 



ENDOLAKYNGEAL OPEBATIONS. 225 

(4) Extensive operations should not be performed 
upon one with organic tuberculosis other than pul- 
monary. 

(5) Those patients who show a marked reaction to 
cocain, i. e., cardiac weakness, fever, insomnia and 
loss of appetite, must not be subjected to secondary 
operations unless some one of the newer and presuma- 
bly non-poisonous anesthetics proves effective and 
harmless. These cases are very rare but of considera- 
ble importance, for when cocain, or the operation 
itself, plays havoc with the nervous and digestive sys- 
tems, it is foolhardy to persist in its use, for the loss 
in general vigor will more than outweigh any possible 
local improvement. 

The entire subject may be condensed by saying that 
no radical procedures for the cure of the larynx should 
be undertaken that entail heavy expense upon the part 
of the lungs or the general strength; it avails nothing 
to cure the larynx and at the same time cause perma- 
nent progression of the general disease. 

In an individual, however, who meets all the above 
requirements, early and complete removal of all dis- 
eased tissue is always indicated provided a fair trial 
of simpler treatment has been unavailingly made. 

The choice of operation depends upon the prefer- 
ences of the individual operator, and upon the size, 
location and character of the lesion but as a general 
rule, it may be claimed that the use of cutting instru- 
ments in far preferable to electric cauterization or 
electrolysis. These may supplement but should rarely 
supplant the methods that aim at thorough removal 
rather than the slow destruction of the diseased tis- 



226 LARYNGEAL TUBERCULOSIS. 

sues, for complete extirpation should be the objective 
no matter how extensive the measures demanded. 

The reaction from galvano cauterization is fully as 
great as from the cutting operations and a dozen ap- 
plications will not as a rule accomplish more than one 
fearless removal of tissue. Electric or chemical cau- 
terization, however, should generally succeed the rad- 
ical operations, in order to destroy any tissue that may 
have escaped the knife. 

OPERATIONS. 

The operations are classified as endolaryngeal and 
extralaryngeal. 

The endolaryngeal operations are : 

(1) Incision and scarification. 

(2) Curettage. 

(3) Galvano cauterization. 

(4) Electrolysis. 

The extralaryngeal operations are : 

(1) Tracheotomy. 

(2) Intubation. 

(3) Thyrotomy. 

(4) Laryngectomy. 

INCISION AND SCARIFICATION. 

Simple deep incisions have an extremely limited field 
of usefulness. Even Moritz Schmidt, who introduced 
the treatment for the relief of dysphagia dependent 
upon edematous infiltrations of the epiglottis, aryte- 
no-epiglottidean folds and posterior wall, has aban- 
doned it to a large extent. 



ENDOLAKYNGEAL OPEKATIONS. 227 

As a pure palliative procedure it lias some merit in 
a limited type of cases; those in which dysphagia de- 
pends npon extensive infiltration of the posterior wall. 
With a pair of angular scissors an incision is made 
through the laryngopharyngeal wall, down to and in- 
cluding the interarytenoid incisure. 

Under 20 per cent cocain anesthesia the pain is 
not severe and usually completely disappears by the 
end of the second or third day. For from three days 
to a week feeding by the rectum is necessary, by which 
time the edges of the wound will have united firmly 
enough to permit the swallowing of liquid and semi- 
solid food. 

The relief of pain is generally marked, temporary 
arrest of the process is not extremely rare and in- 
stances of enduring cure are on record. Hemorrhage 
and the falling forward into the larynx of one flap are 
the only accidents to be apprehended. Bleeding is 
never uncontrollable and the forward displacement of 
a flap can usually be avoided by maintaining a recum- 
bent posture during the period of healing ; if this fails 
the prolapsed part should be removed with the double 
curette. 

Deep incisions have sometimes been advantageously 
employed in cases of smooth diffuse infiltrations as^i 
preliminary to the use of lactic acid, but since the in- 
troduction of the more penetrating pigments the 
method has become largely obsolete. 

In edema scarification causes considerable shrink- 
age with a corresponding decrease of the subjective 
symptoms. Either a single deep linear incision or 
multiple punctures can be made. 



228 LAKYNGEAL TTJBEKCULOSIS. 

A deep incision into the epiglottis extending from 
free edge to base will oftirnes relieve the dysphagia 
dne to tense infiltrations or perichondritis, bnt it 
should only be made when for any reason complete 
amputation seems inadvisable. 

CURETTEMENT. 

The term curettement embraces excision as well as 
simple scraping or evidement. 

Of all endolaryngeal surgical procedures it is the 
one most commonly employed and most generally 
useful. Introduced to the profession by Heryng in 
1887 (D. Heilbark. d. Larynx PMMsie), it has steadily 
gained wider acceptance until its general worth is now 
almost universally acknowledged, although it must be 
admitted that in America surgical treatment has not 
gained the recognition accorded it on the Continent. 

Local anesthesia is a necessary precursor of every 
laryngeal operation and must be sufficiently complete 
to destroy all mobility and reflex irritability. For the 
more delicate maneuvers the pharynx and palate must 
be included in the anesthesia. The larynx is first 
sprayed with a weak solution of cocain or alypin, 2 
per cent, until superficial sensibility is deadened, then 
repeatedly mopped with a 10 to 20 per cent solution. 

The simultaneous use of adrenalin chloride, 1 to 
10,000, increases the effectiveness of the cocain and 
permits of the operation being concluded without the 
field becoming obscured by blood. At the same time 
it decreases the chances of constitutional depression. 

In exceptional cases, even when a 20 per cent cocaiii 
solution lias been freely used, the mere introduction of 



EKDOLAKYNGEAL OPEKATIONS. 229 

an instrument will produce an immediate cramp of the 
glottis ; in such cases the cocain will have to be intro- 
duced by snbmncons injection. 

The hypodermic administration of morphin and 
atropin, thirty minntes before the operation, is par- 
ticularly serviceable in nervous patients and in those 
in whom it is desirable to prevent a free excretion 
of mucus. 

A full half hour is commonly required before the 
larynx can be brought under perfect control. Con- 
stitutional effects are rare, much more so, in fact, than 
from the use of corresponding amounts in the nose and 
pharynx. 

Preliminary cleansing of the larynx, except for the 
removal of mucus and pus at the time of operation, is 
unnecessary. The use of creosote and iodoform for 
five or six days preceding operation, as advised by 
Mascarel (Trait e chirurg. d. vegetations d. I. laryngite 
tuber 'cl. These Paris, 1890) and Castex (Traite chir. d. 
I. pMMsie lar. Ann. d. mat de Vor, July, 1893), is purely 
gratuitous, as a single act of coughing immediately 
before or during the operation renders the larynx as 
septic as if preliminary cleansing had been entirely 
omitted. 

INSTBUMENTS. 

The instruments required include single curettes, 
double curettes or cutting forceps, knives, and galvano- 
cautery points and snare. The two sets of curettes 
known as the Heryng and the Heryng-Krause meet all 
requirements and are universally applicable. 



230 



LARYNGEAL TUBERCULOSIS. 



The former consists of knives and single cnrettes of 
various sizes and shapes, attachable to a universal han- 
dle and adjustable at any desired angle. (Fig. 58.) 

The Heryng-Krause instruments, comprising the 
double curettes or tube forceps, may likewise be at- 




Fig. 58. 



1 ached in any position to a universal handle. (Fig. 59.) 

The set of double curettes made by Pfau are admir- 
ably suited for the more delicate operations. (Fig. 60.) 




Fig. 59. 



To replace the tube forceps Lake has designed vari- 
ous punch forceps which are of considerably greater 
power. 

The first of these lias an oval cutting edge sot at 
an oblique angle with Iho shaft and is designed for 



ENDOLARYNGEAL OPERATIONS. 



231 



operations upon the interarytenoidal region. (Fig. 61.) 

Fig. 62 shows a powerful forceps of large size for 
excision of the epiglottis. 




Fig. 60. 

The third instrument (Fig. 63) has a circular cutting 
edge and is designed for any part of the larynx above 
the rima glottidis with the exception of the interary- 
tenoid sulcus. 




Fig. 61. 



For removal of the epiglottis either the forceps or 
the galvano-cautery snare (the Schech handle is most 
convenient) can be used. 



232 



LARYNGEAL TUBERCULOSIS. 



The author has modified the familiar lingual tonsil- 
litome to fit the epiglottis and has found it more gener- 




Fig. 62. 



ally satisfactory than any of the punch forceps. It re- 
moves nearly all of the organ in one piece, the detached 
part cannot fall into the larynx, and the operation is 




Fig. 63. 

performed with great rapidity and a minimum of pain, 
desiderata of great value in most cases. (Fig. 64.) 

INDICATIONS FOR SIMPLE CUEETTEMENT. 

(1) Removal of friable granulations and tumors. 

(2) Removal of sharply circumscribed infiltrations. 



EKDOLAKYNGEAL OPEKATIONS. 



233 



(3) Stimulation and cleansing of sluggish ulcers. 

Curettement, when thoroughly done, is sometimes a 
procedure of considerable difficulty. The tuberculous 
larynx is often exceedingly sensitive, so irritable in 
fact, that despite thorough cocainization, every effort 
at manipulation provokes uncontrollable seizures of 
coughing and cramp. 




Fig. 64. 



This is especially true of lesions involving the pos- 
terior wall and interarytenoid incisure, success, in 
some instances, following only after repeated attempts. 
Many skilled laryngologists support this view, notably 
Schech (Handbuch der Laryngologie, Pg. 1168), Krieg 
(Ueb. Ort. Behandl. d. Kehlkopf. tuber x. Corr. Bl. f. 
Wurtz. Aerzte, Nr. 32, 1894) and Hajek (D. loc. Be- 
handl. d. Kehlkopf. tub ere. Centralb. f. ges. Ther. Nr. 
2, 1895). 



234 LABTNGEAL TUBEKCULOSIS. 

Schaifer (Ueb. d. Curettement d. Larynx. Ther. 
Monatsli., Oct., 1890) admits that it is generally easier 
for him to remove a laryngeal polypus, no matter 
where situated, than to properly curette a tuberculous 
lesion that extends well down in the inter arytenoid 
sulcus. This point has been particularly emphasized 
because curettement is usually looked upon as the sim- 
plest of laryngeal operations, to be performed by 
every novice in laryngology. 

The consistency of the growth must always be taken 
into consideration, for with the single curette it is 
practically impossible to remove some infiltrates, i. e., 
those tough, firm swellings of the posterior wall that 
bear a strong resemblance to true fibrous or scar tis- 
sue. Neither can it be satisfactorily employed upon 
the free edge of the epiglottis nor upon the tip of the 
arytenoid cartilages, owing to their non-resistance to 
firm pressure. 

The lesions most adapted to simple curettement are 
localized infiltrations and sluggish ulcers of the true 
and false cords, the laryngeal surface of the epiglottis, 
and the interarytenoid sulcus. Acute lesions, those asso- 
ciated with edema and high fever, generally contra- 
indicate currettage. 

Thoroughness is an absolute essential and a second 
scraping is permissible, if necessary, as soon as the 
slight reaction consequent upon the preceding opera- 
tion lias subsided. Immediately after the operation, 
pure lactic acid or 10 per cent formalin should be 
thoroughly rubbed into the wound. 



EXDOLAKYNGEAL OPEBATIONS. 235 

EXCISION. 

Excision is the method par excellence in those cases 
in which complete removal of the morbid tissne is 
possible. 

Contrary to the usually accepted dictum that ex- 
cision should be limited to those cases with sharply 
circumscribed lesions, the author frequently operates, 
with good effect, upon patients in whom the disease is 
so extensive as to preclude the possibility of complete 
extirpation. 

This is only done, however, when all other treatment 
has proven ineffectual, or in cases with obsti- 
nate dysphagia. Partial removal, except in cases 
with extremely numerous and disseminated foci, ren- 
ders the remaining tissue more amenable to medicinal 
treatment. 

That this procedure is sound has been repeatedly 
demonstrated in the author's practice. It must be ad- 
mitted that this is directly contrary to the experience 
of almost all laryngologists and these more favorable 
results must undoubtedly be due in large part to cli- 
matic influences. 

Many objections have been raised to any radical 
operative interference : 

(1) The danger of causing increased activity in the 
pulmonary disease or of producing general tubercu- 
losis. 

(2) The impossibility of removing all diseased 
tissue. 

(3) The proven fact that recurrences are frequent. 

(4) The technical skill requisite for operating. 

(5) The danger of infecting new tissue. 



236 LARYNGEAL TUBERCULOSIS. 

(6) That the mere removal of tuberculous tissue 
does nothing to prevent new infections from the lungs. 

In regard to the first and most valid objection little 
of real value can be adduced. In a few cases there has 
been a post operative exacerbation of the general pro- 
cess, but such careful observers as Heryng, Grleitsmann 
and Krieg, hold that a connection between the two has 
not been proven and that the increase in pulmonary 
activity might well have been accidental. 

On the other hand, Eethi, Lermoyez and Sokolowski 
have seen cases in which the dependence of the general 
infection upon surgical procedures seems to have been 
definitely established. 

In a large series of operative cases the author has 
never met with one, where the general nutrition was 
fairly good and the lung condition quiescent, in which 
any harmful effects from the laryngeal work became 
evident. In a number of cases of advanced pulmonary 
disease the operations did unquestionably cause some 
temporary activity. While the danger is a possible 
one, it is extremely remote and should never be allowed 
to interfere with a necessary operation ; laryngeal tub- 
erculosis, of itself, often leads to excrutiating pain 
and death unless vigorously combatted and checked, 
and hence a slight possibility of disseminating the in- 
fection cannot be considered a valid contra-indication. 

Schrotter based his objections to surgery upon the 
assumption that the tuberculous tissue cannot be so 
thoroughly removed as to eliminate all possibility of 
recurrence. It is true that recurrences after one to 
five years are distressingly frequent, but it is equally 
true that the percentage of enduring cures is not in- 



ENDOLAKYNGEAL OPEKATIONS. 237 

creased by other methods of treatment, and in the ma- 
jority of instances in which the disease has reappeared, 
it can be shown that life has undoubtedly been pro- 
longed, and much suffering averted, by reason of this 
early intervention. Moreover, many cases have been 
completely cured that would have otherwise 
succumbed. 

Neither is a complete extirpation essential to tem- 
porary arrest or even to absolute cure. Most gratify- 
ing results are sometimes attained in patients where 
a partial removal of diseased tissue is followed by 
long periods of medicinal treatment and the author, 
personally, no longer seriously considers the extent of 
involvement, provided it is not so widespread as to 
absolutely preclude the possibility of benefit. 

When there is generalized extrinsic, or combined ex- 
trinsic and intrinsic infection, it is self evident that 
endolaryngeal surgery should be limited to those pro- 
cedures requisite to the relief of dysphagia^ but one 
should not be invariably deterred by the simple fact 
that a lesion has progressed beyond a point permitting 
of complete removal. 

Excision of a ventricular band, of an arytenoid car- 
tilage or an ary-epiglottic fold can rarely be complete, 
yet their partial removal, even when extensively dis- 
eased, results frequently in complete healing or, at 
the least, prepares the way for more successful medic- 
inal treatment. 

Partial removal is advisable in all cases of even ex- 
tensive involvement provided medicinal treatment and 
simple curettement have failed, for chemical agents 
then become more effective and the patient is not alone 



238 LAKYNGEAL TTJBEKCULOSIS. 

given a better chance of complete or temporary arrest 
but of more prompt relief as well. 

Immediate cure is not to be thought of in any case, 
prolonged after treatment being an invariable essen- 
tial no matter how thorough the excision. 

That an operation demands unusual skill upon the 
part of the surgeon cannot be held as a rational argu- 
ment against its performance, for few of the life sav- 
ing operations can be performed with equal skill by all 
surgeons, and each must necessarily be left to those 
especially equipped by nature and training. 

That there is danger of infecting new tissues is theo- 
retically correct but its occurrence in practice has rare- 
ly been observed, and the same holds true in regard to 
the liability of causing mixed infection. 

In extralaryngeal operations infection of the line of 
incision is not rare and offers one of the strongest ob- 
jections to such methods but in endolaryngeal work it 
is extremely uncommon even when preventive meas- 
ures have been neglected. The wound, even when much 
diseased tissue is left, heals promptly as a rule. 

Some twenty-four amputations of the epiglottis have 
been made by the author without in a single instance 
having an infected stump, and practically every case 
was complicated by advanced pulmonary disease and 
involvement of other segments of the larynx. 

The chief danger lies in wounding the epiglottis, 
either through prolonged pressure or direct trauma- 
tism, but this can usually be avoided by correct and 
careful technique. 

To the last objection, i. e., that the removal of the 
t uIkmvuIous tissue does not prevent new infections from 



ENDOLARYNGEAL OPERATIONS. 239 

the lungs (Solly, Laryngoscope, June, 1904) it need 
only be said that the same objection applies with equal 
force to all other treatments. 

Should all intervention be therefore abandoned! 

The indications for the use of the double curette, as 
given by Schech, are : 

(1). Eemoval of circumscribed or not too diffuse 
infiltrations of the epiglottis, ventricular bands, the 
posterior wall and ary-epiglottic folds. 

(2). Ulcerations of the epiglottis, ary epiglottic 
folds and arytenoid cartilages accompanied by severe 
dysphagia. 

(3). All cases of infiltrations and granulations 
which because of their consistency cannot be re- 
moved by the single curette. 

As already mentioned, ulcerations or limited infiltra- 
tions of the tips of the arytenoids and the edge of the 
epiglottis, cannot be satisfactorily removed with the 
single curette; with the double instrument, however, 
the required amount of tissue can be easily excised. 

Complete amputation is nearly always indicated 
when there is extensive involvement of the epiglottis. 
In such cases, because the rest of the larynx has usual- 
ly already succumbed, the prognosis is highly unfavor- 
able and little can be expected from operative treat- 
ment a^de from the relief of pain. A not inconsider- 
able number, however, approximately 10 per cent, are 
permanently cured, a much better showing than that 
made by other methods of treatment. 

The cures are naturally most liable to occur with 
those in whom the remaining segments of the larynx 
are not extensively involved. The results are usually 



240 LARYNGEAL TUBERCULOSIS. 

brilliant in so far as the relief of pain is concerned, a 
relief that is almost instantaneous, a sufficient reason 
for operating in every severe and obstinate case. 

The earlier the operation is performed the greater is 
the prospect of ultimate recovery, hence, in the average 
case, the entire organ should be removed the moment 
the futility of the simple procedures has become mani- 
fest. No other part of the larynx proves so rebellions 
to' treatment and since these lesions are nearly always 
provocative of severe dysphagia, which cannot endure 
long without producing marked cachexia and rapid ad- 
vancement of the pulmonic process, the offending tis- 
sue should be excised before these conditions have su- 
pervened and rendered all treatment futile. 

In advanced cases operative treatment is alone ef- 
fective and in the incipient, if they prove unresponsive, 
should be instituted as early as possible in order to 
avoid extension to contiguous tissues and the produc- 
tion of severe constitutional symptoms. 

With the double curette, Lake's or Pfau's forceps, 
or the author's guillotine, the entire organ can be read- 
ily removed, especially when it is brought into direct 
view by a Kirstein tongue depressor. 

If the galvano cautery snare is used the loop must 
be pressed well down to the base so as to include the 
entire organ, and drawn taut before the current is 
turned on. When the constricted portion is burned 
Hi rough, the current is turned off and the loop again 
tightened, and so on until the entire organ is severed. 
Before separation is complete the fragment should be 
seized with forceps to prevent it from falling into the 



ENDOLARYNGEAL OPERATIONS. 241 

larynx. Hemorrhage is rarely sufficient to occasion 
any alarm. 

The author's preferences are strongly in favor of 
the cutting forceps over the cautery because the opera- 
tion is more rapidly completed, the reaction is less se- 
vere, healing is more prompt and the instrument is 
under more perfect control, permitting more accurate 
adjustment to the proposed line of excision. 

Complete excision can likewise be employed in invol- 
vements of the arytenoid cartilages, no matter how ex- 
tensive, provided there is no accompanying disease of 
the arytenoepiglottidean folds. 

The results have usually been favorable both in re- 
spect to relief of pain and arrest of the process. 

If the aryepiglottic folds are extensively diseased the 
prognosis is most grave but their radical removal is 
rarely permissible. If, however, the ulcerations are 
strictly circumscribed and unattended by edema or 
massive infiltration, they may be punched out with the 
double forceps. 

When the ventricular bands are so infiltrated as to 
overhang the vocal cords and threaten interference 
with breathing, they should be cut back, removing as 
much tissue as is practicable. 

Owing to the danger of hemorrhage in such cases, 
especially if the infiltration is hard and firm, galvano- 
cauterization or electrolysis is generally preferable. 

Subglottic lesions are not often operable but when 
large enough to be seized, they can be removed by 
Scheinmanns' or some similar forceps. The single 
curette is more often applicable. 



242 LAKYNGEAL TUBEKCULOSIS. 

AFTEE TREATMENT. 

The larynx must be given complete rest for several 
days. 

Immediately succeeding the operation, pure lactic 
acid or formalin, 10 per cent, should be applied thor- 
oughly, followed by the insufflation of orthoform and 
aristol. The larynx is also to be sprayed at intervals 
of two to three hours with an alkaline solution contain- 
ing one-half per cent of formalin. 

If there is marked inflammatory reaction, adrenalin 
chloride, 1-10,000, used as a spray at frequent intervals, 
is of decided benefit, and inhalations or injections of 
menthol in oil are temporarily soothing. 

The local application of cocain and morphin is 
sometimes necessary, and rectal feeding is advisable 
for two or three days, although not invariably essential. 

The reaction, however, is usually slight and constitu- 
tional symptoms, i. e., headache, fever and prostration, 
exceptional. 

The temperature occasionally rises from one to three 
degrees, but persists for not more than one or two days. 

Hemorrhage is rare and when it occurs is easily con- 
trolled. Heryng has seen but two severe cases in 270 
operations, both occurring after removal of the ven- 
tricular bands. Moritz Schmidt has also had but two 

cases. 

If severe bleeding does occur adrenalin chloride 
should be freely applied, and if this proves inopera- 
tive, equal parts of lactic acid and sesqui chloride of 
iron. 



ENDOLABYNGEAL OPEBATIOJNS. 243 

GALVANO-CAUTERIZATION. 

Galvano cauterization has an important though ex- 
tremely limited field of usefulness. The lesions to 
which it is particularly adapted are dense firm infiltra- 
tions of the ventricular bands, anterior commissure of 
the cords, and subglottic region. It is also of occa- 
sional service in promoting cicatrization of unduly 
sluggish ulcers, although for this purpose the curette 
is more generally applicable and effective. 

The cutting away of the ventricular bands is liable 
to provoke considerable bleeding, hence in these cases 
the use of the cutting forceps has in large part been su- 
perseded by electric cauterization. In the subglottic 
region and at the anterior commissure it is largely a 
question of accessibility; if the infiltrated tissues can- 
not be grasped by the forceps they must be destroyed, 
in so far as possible, by the cautery. 

For dysphagia dependent upon infiltration of the 
posterior wall, both Gleitsmann and Price-Brown advo- 
cate the use of the cautery, a procedure which the au- 
thor cannot unequivocally endorse. In such cases, if 
the infiltrate is sufficiently massive to require numerous 
deep punctures, the reaction may be so severe as to 
materially increase the dysphagia for some days, and 
the results are generally less satisfactory than from the 
more radical procedures. The cauterization may be 
made with complete safety, however, when the lesions 
are only of moderate extent, and in such cases may be 
of considerable service in helping to differentiate be- 
tween the thickenings due to early tuberculosis and 
chronic catarrhal laryngitis. 



244 LAKYNGEAL TUBEKCULOSIS. 

In applying the cautery the point must be buried 
deeply in the tissues, penetrating as nearly as possible 
to the base of the lesions, the number of punctures de- 
pending upon the extent of involvement. Edema rarely 
occurs, there is no danger of after infection, and the 
pain is not severe. 

Secondary applications are not allowable until after 
complete separation of the resultant scab. 

ELECTROLYSIS. 

Although the destruction of tuberculous tissue by 
electrolysis has been advocaed since the year 1889, the 
method has never become popular owing to the uncer- 
tainty of the results, the time consumed in treatment, 
and the pain inflicted. 

It possesses no advantages over the true surgical 
precedures, except in rare instances, and in these the 
indications are more effectively, and more promptly 
met, by galvano-cauterization, i. e., firm infiltrations 
that cannot be grasped by the forceps, and in localities 
where incision is likely to provoke hemorrhage. 

Simple infiltrations of the vocal cords that resist 
medicinal treatment occasionally respond to electroly- 
sis, but even in these cases cauterization is more ef- 
fective. 

( Opinions as to its usefulness are not unanimous, how- 
ever. 

Kafemann (Ueb. Electrolyse, u. i. An wend, b. Er- 
krank, d. Nase u. Rachens m. spec Berucks, d.-Lar. tu- 
bercul. Ther. Monatsh. L893) formerly recommended 
elecl rolysis for hard, tumor Like infiltrations of the ven- 
1 ricular bands, for chorditis vocalis inferior, for tumor- 



ENDOLARYNGEAL OPERATIONS. 245 

like swellings of the aryepiglottic folds, and for flat 
infiltrations of the epiglottis. His early favorable im- 
pressions, however, were not supported by later expe- 
rience. 

The nnipolar method is commonly used, the laryn- 
geal electrode being attached to the cathode. The 
current varies from 20 to 50 milliamperes, beginning 
with the weaker current and gradually increasing as 
the patient becomes accustomed to the applictions. 

Each treatment should last from one to three 
minutes. 

The pain is considerable even after thorough cocain- 
ization. 



CHAPTEE XIV. 

SUEGICAL TEEATMENT.— EXTEALAEYNGEAL 

OPEEATIONS. 

TKACHEOTOMY. 

In cases of advanced laryngeal tuberculosis with in- 
cipient or no demonstrable pulmonary involvement, 
tracheotomy is a rational procedure that promises 
moderately favorable results. 

In no case, however, regardless of the conditions, 
should a tracheal cannula be introduced until all of the 
less radical methods of treatment have been unavailing- 
ly applied. 

In four types of the disease the operation may oc- 
casionally, though rarely, be indicated. 

(1). Advanced laryngeal without pulmonary invol- 
vement. 

(2). In children so young as to preclude the pos- 
sibility of successful intralaryngeal treatment. 

(3). In cases of extreme and rapidly progressive 
stenosis. 

(4). In certain cases complicated by pregnancy. 

< )f the curative value of tracheotomy, Moritz Schmidt 
(Ueb. Tracheot. \>. KeMkopfschwindsucht 1). Med. 
Woch. Nr., 4:1, L887) has long been the mosl ardent ad- 
vocate, and his views have been endorsed to a certain 



EXTKALAKYNGEAL OPERATIONS. 247 

extent by Chiari, Seifert, Castex, Keimer, Gaudier, 
Henrici, Beverly Bobinson, Finder, Grazzi and others. 

Many equally distinguished laryngologists, among 
whom may be mentioned Hofmann, Lennox Brown, 
Tietze, Massei, Morrell Mackenzie, B. Frankel, and 
Gouguenheim, utterly condemn the procedure. 

That the operation exerts a marked, curative effect 
cannot be questioned in the face of the many reported 
cases of complete healing and the yet larger number in 
whom temporary arrest resulted, but the good effects 
in the majority of instances are more than outweighed 
by its unfavorable influence upon the pulmonary pro- 
cess. 

If the lung condition is perfectly quiescent it may 
possibly remain so despite the operation, but if there 
is any activity the wearing of a cannula is almost cer- 
tain to cause grievous mischief. 

It is extremely rare to find advanced laryngeal dis- 
ease unassociated with active lung lesions, and practic- 
ally all cases of this so-called "primary" laryngeal 
phthisis are curable by medicinal or endolaryngeal sur- 
gical treatment, so it is a self-evident fact that a ques- 
tion concerning the advisability of tracheotomy almost 
never arises. 

Moritz Schmidt himself made later acknowledgement 
that the more frequent performance of endolaryngeal 
operations reduced greatly the number of cases in 
which he was forced to perform tracheotomy. 

The literature shows a large number of reported 
cures but it will suffice to record one, a typical case, 
described by Price-Brown (Ann. Otology, Ehinology 
and Laryngology, June, 1903). 



248 LAKYNGEAL TUBEKCTJLOSIS. 

This patient, a man of 30 years, had severe and prog- 
ressive dyspnea dne to enormons infiltration of the 
epiglottis, completely hiding the arytenoids and vocal 
cords. One year previous, both his lnngs and larynx had 
shown advanced disease, "considerable deposit in the 
right apex, extensive consolidation in the left apex, and 
down the posterior side of the left lnng as far as the 
seventh rib; xxx larynx infiltrated, particularly the 
left side of the epiglottis. Ulceration along the mar- 
gin of the left vocal cord, slight abrasion of the left 
arytenoid and ary epiglottic fold." 

At the time of operation his pulmonary condition 
had greatly improved and expectoration had almost 
ceased. 

In June, seven months after the operation, ' ' the in- 
filtration of the epiglottis has very much diminished; 
the left side which was so enormously infiltrated has 
shrunk to less than normal size. There are no visible 
ulcerations. ' ' 

Henrici (Archiv. f. Laryngologie u. Rhinologie, B. 
15, H. 2) reports four successful cases. 

Serkowski (Allgem. Med. Chi. Zeitung, Aug., 1878) 
reported one case alive three years after operation, and 
Schmidt recorded seven cures. 

On the other hand many operators have failed to 
observe any curative effects whatsoever, for example, 
Morrell Mackenzie operated twelve cases and in not a 
single one was there visible improvement in the patho- 
logical process. 

I have performed the operation five times in all ; of 
these patients two were well after twelve and eighteen 
months respectively ; on died after 11 hours ; one sue- 



EXTEALAEYNGEAL OPEEATIONS. 249 

cunibed to pulmonary tuberculosis after four months, 
the larynx having in the meantime showed no recur- 
rence, and one died in seven weeks, the operation hav- 
ing undoubtedly hastened the end. 

Of these the first two were cases of moderately ad- 
vanced laryngeal phthisis with, in both instances, a 
pulmonary lesion limited to slight consolidation of the 
right apex, cases that offer a hopeful prognosis from 
even simple medicinal treatment. The third was a 
case of sudden abductor paralysis in a young woman 
with advanced pulmonary and laryngeal tuberculosis. 
At the time of operation the entire left side was filled 
with a large pleural effusion. 

Both the fourth and fifth cases had moderate and 
slowly progressive stenosis with fairly widespread pul- 
monary involvement. In these two cases the pulmo- 
nary disease was much aggravated by the operation, 
and extensive endolaryngeal work would undoubtedly 
have been the preferable procedure. 

The curative effects of tracheotomy depend upon the 
complete rest given the larynx and upon its protection 
from irritant dust and pulmonary excretions. Unfa- 
vorable results are the rule, however, and are to be 
credited to some one or more of the following causes : 

(1). Aggravation of the lung disease. 
(2). Tracheal irritation. 
(3). Wound infection. 

With a tube in the trachea cough at once becomes 
weak and ineffectual, the secretions are dammed back 
in the lungs, fever results, and the entire tuberculous 
process takes on new activity. 



250 LABYNGEAL TUBEKCULOSIS. 

Because of this the performance of tracheotomy must 
be unqualifiedly condemned except for certain cases in 
early life, in exceptional pregnancy cases, and in rare 
instances of acute or rapidly progressive stenosis. 

In the so-called primary cases the operation is sel- 
dom necessary because other treatment is effective and 
is attended with little danger, either of local infection 
or of increased activity in the constitutional malady. 

In very young children the difficulty of carrying out 
effective endolaryngeal treatment makes the operation 
of tracheotomy a rational and necessary one, even if 
it be at the risk of increased constitutional disturbance. 

Levy (Annals of Otology and Laryngology, Sept., 
1906) reports a case of a child tracheotomized by him 
for laryngeal papillomata. The tube was worn for a 
considerable period during which the growths were 
being removed, and the child soon developed and died 
from tuberculosis. He credited the pulmonary infec- 
tion to the tracheal opening. 

It is certain that the wearing of a cannula irritates 
the trachea and if its presence favors infection as this 
case indicates, it would naturally cause increased ac- 
tivity in an already existent lesion. 

Tracheotomy even in children should therefore be 
postponed until the futility of all other treatment has 
been proven. 

In cases of extreme stenosis with rapidly progressive 
dyspnea an immediate tracheotomy is sometimes re- 
quired, but early endolaryngeal surgical management 
will practically always avert such symptoms and the 
operation becomes imperative, therefore, only in those 
cases where treatment lias been long neglected. 



EXTKALAKYNGEAL OPEBATIOJSTS. 251 

PBEGNANCY. 

The mortality in cases of laryngeal tuberculosis com- 
plicated by pregnancy is always high no matter what 
system of treatment is instituted. 

Of the seventy-one cases collected by Sokolowski, 
fifty-six died during or soon after confinement, one was 
living after eight years and fourteen disappeared. 

Of fourteen cases operated by tracheotomy, eleven 
died, two were lost sight of after discharge and the 
third was living after eight years. 

Three cases were treated by laryngo-fissure ; of these 
two died and one disappeared one month after success- 
ful delivery. 

Kiittner gives the following resume of 230 pregnant 
women who had diffuse laryngeal tuberculosis : 

"Three survived a natural confinement for one to 
one and a half years, and thirteen for a longer period, 
in all, sixteen, or seven or eight per cent. 

Among these sixteen women are several in whom the 
laryngeal affection did not commence until the latter 
part of the period of gestation. Nearly all surviving 
subjects belonged to the wealthier classes. 

Artifical abortion was induced in twelve cases; in 
nine with good results, in three without success. In- 
duced premature birth was attempted in seven cases, 
in one (middle of the seventh month) with, in six with- 
out success. 

Tracheotomy, or laryngo-fissure respectively, was 
performed fifteen times. Two of these women survived 
confinement one to one and one-half years, two still 
longer, while eleven died soon afterwards. Of these 
230 women about 200 died previous to or shortly after 



252 LARYNGEAL TUBERCULOSIS. 

confinement, either without professional intervention 
or notwithstanding it. 

Of one hundred and sixteen children concerning 
whom we have information, seventy-nine or eighty per 
cent are reported dead; eighteen as living at birth, or 
in the first two years; nineteen as living a longer 
time ; in all thirty-seven or thirty-two per cent. 

In wealthy families the mortality of the children was 
less than among the poor ; likewise do the chances for 
the child seem better when the mother's life is saved.' ' 

Every case of pregnancy complicated by laryngeal 
tuberculosis should be terminated at the earliest pos- 
sible moment; if allowed to continue the prognosis is 
almost hopeless. 

If pregnancy is far advanced, however, and the 
laryngeal infection severe, the induction of abortion 
will probably hasten the fatal result; in such cases 
tracheotomy must be at once performed although the 
hope of a successful issue is slight. 

No patient with tuberculosis of the larynx should be 
allowed to become pregnant but if it does occur the 
earlier abortion is induced the better the prognosis. If 
pregnancy is already far advanced when the case comes 
under observation, tracheotomy is the only recourse. 

INTUBATION. 

Intubation in laryngeal tuberculosis is wrong in 
theory and unsuccessful in practice. 

Stenosis sufficiently advanced to require radical sur- 
gical treatment demands tracheotomy or thyrotomy 
and not intubation. 



EXTRALARYNGEAL OPERATIONS. 253 

The intubation tube acts as an active irritant, caus- 
ing severe pain, local inflammation, and increase of 
cough with early expulsion of the tube. Subchordal 
and chordal lesions alone can be influenced by the tube 
and disease of these segments rarely leads to serious 
dyspnea. 

The stenosis of tuberculosis is an essentially chronic 
process (cases of acute tuberculous edema are rare 
and are responsive to medicinal treatment or to scari- 
fication) and tubes of this character can have no per- 
manent influence. 

THYROTOMY. 

The operation of thyrotomy has not been performed 
in a sufficient number of cases to definitely establish 
its true sphere and worth. The results in the compara- 
tively few cases already recorded have not been bril- 
liant, although they have been sufficiently encouraging 
in a few instances, to warrant the belief that it may be 
justified in cases of advanced laryngeal with incipient 
pulmonary disease, provided all other treatment has 
failed. 

A careful review of the literature reveals 43 cases, 
a considerable proportion of which were operated be- 
cause of a mistaken or doubtful diagnosis. 



254 



LAKYNGEAL TUBEKCULOSIS. 



Observer Cases 

Billroth 1 

Dehio 1 

Henning 2 

Schonborn 4 

Hopmann 4 

Kuster 2 

Schnitzler 1 

Koch 1 

Griinwalcl *2 

Kijewski 1 

Baurowicz 1 

Taptas 1 

Gerster 1 

Lock 1 

Goris 4 

Bond t2 

Symonds $2 

Sokolowsky 1 

Schmiegelow 1 

Kuttner 2 

Schmidt 2 

Chavasse 1 

Gluck 1 

Stein 2 

Lockard 2 

Total 43 

* 1 Unfavorable. t 1 Unfavorable. 



Deaths 

1 
1 

1 

o 
O 

1 

1 



Improvement 



1 
2 
3 
2' 
1 
1 
2 
1 
1 
1 
1 
1 
4 
1 

1 
1 
2 
2 
1 
1 
2 
2 

34 

t 2 Unfavorable. 



A study of these cases shows that four died soon 
after operation without laryngeal improvement; five 
improved locally but died shortly afterwards from the 
lung disease; four are classed as "unfavorable," and 
thirty-four improved locally or locally and generally. 

Among the improved cases are three that ended fa- 
tally but in which the laryngeal symptoms had appre- 
ciably lessened. 

These statistics are of small value in that the word 
"improved" means but little, for some temporary bet- 
terment is the almost invariable consequence of all 
treatments, whether surgical or medicinal, in cases 
where the Lung condition is favorable. 



EXTEALABYNGEAL OPEEATIONS. 255 

The perniancy of relief alone offers a standard by 
which to jndge of the comparative effectiveness of the 
various systems of treatment, and npon this point the 
records are incomplete. 

One of Griinwald's patients showed no signs of re- 
currence after thirteen months; one of Hopmann's, a 
preacher, continued to use his voice in public after 
eleven years ; Goris is credited with four cured cases, 
and Schmidt had one patient still well after six months, 
and one in whom there was no recurrence at the end of 
two years. 

Otto Stein (Laryngoscope, October, 1904) operated 
two cases; one showed no signs of return nearly two 
years after operation, and the other, one year after 
operation, was cured as to the throat lesion and much 
improved in general health. 

The patient reported by Chavasse lived in compara- 
tive comfort for fifteen months. 

One of the author's cases, operated in 1901, was liv- 
ing four years later with no subjective symptoms, but 
the throat had not been examined since a few months 
after operation. In this case there was widespread 
laryngeal involvement; great infiltration of both ven- 
tricular bands and both arytenoids, with ulceration of 
the interarytenoid sulcus and the posterior ends of 
both cords. The pulmonary condition was highly fa- 
vorable, only slight involvement at the right apex, no 
temperature and practically no cough or expectoration. 

The second case died after five months but the laryn- 
geal lesion had not recurred. 

Th. Gluck of Berlin (Annals of Laryngology > Sept., 
1904) describes his method of operating and records a 



256 LAKYNGEAL TUBEKCULOSIS. 

case that had no recurrence after seven years. He 

says: 

"In tuberculosis of the larynx and epiglottis, where 
an extensive surgical operation is required, I pursue 
the following technique: Total laryngo-fissure, exen- 
teration of the larynx, with excision of diseased carti- 
lage, extirpation of the epiglottis, as a final step, free 
use of the cautery, then iodoform tamponade of the 
wound and the insertion of a canula. The patients can 
swallow after this operation without the slightest dif- 
ficulty. 

After about eight days, a little of the cartilage is 
resected from the fissure of the thyroid and cricoid 
cartilages. 

Total laryngoplasty, using pedunculated flaps, or, 
where possible, bridge flaps, and fixing them to the mu- 
cous membrane of the pyrif orm sinus, and to the lateral 
and posterior aspects of the trachea by means of ac- 
curately applied sutures. 

One or two sutures also fix the flaps in the depth of 
the laryngeal cavity. Preferably these flaps are taken 
from the submental region. If the patient has a beard 
we must take the flaps form a hairless part of the face. 
The flaps are also partly secured by iodoform packings. 
After healing occurs, the patient has an artificial laryn- 
goschism which, however, does not interfere with 
speech, because the two edges of the thyroid cartilage 
come together. By these plastic operations one can 
(ill out the whole laryngeal cavity with skin grafts and 
this skin lakes on the character of mucous membrane. 

I performed this operation for the first time seven 
years ago, with excellent results, od a young merchant. 



EXTKALAKYNGEAL 0PEKATI0NS. 257 

He still remains in perfect health. I had removed one 
of his testicles for caseous tuberculous orchitis and 
epididymitis. He suffered from pulmonary tubercu- 
losis, with severe dysphagia and dyspnea. 

In this case I may claim with perfect right, that by 
means of total laryngoplasty, I formed a new larynx 
for him. The patient does not wear a canula, but 
breathes through his laryngo-fissure, seems perfectly 
well, and attends to business. 

He speaks in a loud tone of voice, which he can modi- 
fy, and he can sing the notes of the scale. His cutane- 
ous aditus laryngis is an elliptical slit, about twice the 
size of a split pea ; and thanks to the fact that the ex- 
pired air causes the free edges of this slit to vibrate, 
he can speak excellently well and loud. Had the slit 
been too wide he would at most have been able to 
whisper. In other words we here have a case of laryn- 
geal tuberculosis, treated as a local tuberculosis, and 
as a result, permanent healing was secured. ' ' 

The patient operated by Taptas was much improved 
in general health, and showed no signs of local recur- 
rence, two and one-half months after operation. 

Other so-called cures are recorded but the data is 
insufficient for conclusive deductions. 

Goris, in a compilation of 14 cases, records nine 
deaths within six months of operation, four complete 
cures, and one death where the larynx was cured, but 
the patient died after two years from pulmonary tu- 
berculosis. 

Thus while the statistics show a fair number of en- 
during cures, the fact must not be overlooked that the 
type of disease for which the operation is peculiarly 



258 LAKYNGEAL TUBEKCULOSIS. 

qualified is one that will respond equally well, and usu- 
ally much better, to simple medicinal, or at most, to 
radical endolaryngeal surgical treatment. 

Thyrotomy is absolutely contraindicated in cases of 
advanced pulmonary disease and in those with active 
lesions no matter how circumscribed. It may, perhaps, 
be occasionally justifiable in cases of slight pulmonary 
involvement associated with far advanced laryngeal 
disease, but only in case the laryngeal condition has 
been steadily progressive despite radical endo-laryn- 
geal surgical treatment. 

Such cases are exceedingly rare. 

Thyrotomy, like tracheotomy, usually stimulates the 
pulmonary process into renewed activity, hence ex- 
treme care in the selection of cases for operation is es- 
sential. 

As a pure palliative procedure the operation is un- 
warranted, for more certain relief is afforded by other 
and less dangerous methods. 

LARYNGECTOMY. 

All observers agree that total excision of the larynx 
for tuberculosis is never permissible. 

If one had to deal simply with an advanced, primary 
infection the question would be entirely different, but 
probably without exception the laryngitis is secondary 
to foci in other organs, usually of the lungs, and com- 
plete eradication of the disease in therefore impossible. 

The operation has been performed a number of times, 
((jJussenbauer, Koclier, and Lloyd) and generally be- 



EXTKALAKYNGEAL OPEKATIONS. 259 

cause of having mistaken the tuberculous for a carcino- 
matous growth. 

The mortality from laryngectomy, whatever the na- 
ture of the disease, is exceedingly high, and it is es- 
pecially so in tuberculosis where the general condition 
is usually poor. 

Increased activity in the lungs is an invariable se- 
quel, and the unfortunate patients' condition, al- 
ready deplorable, is greatly aggravated. 

In certain rare cases of thyroid perichondritis a par- 
tial removal may be necessary but complete excision is 
to be unqualifiedly condemned. 



CHAPTEB XV. 

THE NOSE. 

The entrance of tubercle bacilli into the nmcoiis mem- 
brane of the nose may be followed by the development 
of one of two groups of phenomena, the tuberculous or 
the lupoid. 

Clinically the two processes are usually distinct but 
their practical identity must nevertheless be admitted : 
they develop from the same bacillus, their symptoma- 
tology differs but little and that largely in virulence or 
intensity, and their histologic structure shows varia- 
tions in grade of development only, not in type. 

Independent only in name and certain minor symp- 
tomatic and unknown etiologic considerations, a com- 
prehensive discussion of either disease, without em- 
bracing the other to a certain extent, is impracticable. 

Because of this dual nature the literature is both vo- 
luminous and to a certain extent misleading, many ob- 
servers having maintained the absolute identity of the 
two processes, while others persisted in classifying 
them as distinct pathologic entities. 

Even in many modern case reports it is impossible 
to determine definitely which of the two conditions 
actually existed. 



HISTOKY. 261 

HISTORICAL SURVEY. 

Lupus of the external nose was described as early 
as the year 1798 (Willan, Cutaneous Diseases), but its 
occurrence upon the intra-nasal mucosa was not re- 
corded until fifty years later, when Cazenave ( (a). 
Abege; (b). Mem. s. I. Coryza Chron., 1847-1848) gave 
the following description: 

i i Frequently this form of lupus begins upon the nasal 
mucous membrane, and in this locality extends with un- 
usual rapidity, sometimes until the entire septum is 
destroyed before ulceration begins upon the skin sur- 
face. On the other hand it may bore through the floor 
of the nose, extend forward upon the palate, and form 
deep grooves in the gums." 

The first authentic observation of a true tuberculous 
lesion of the nose — a septal ulcer — appears to have 
been made by Willigk, in 1856 (Frag. Vierteljahrsschr. 
f. prakt. Heilk, 13 Jahrgang), the result of 476 autop- 
sies upon tuberculous cadavers. 

From this time a full score of years elapsed before 
record was made of the first definite case of tuberculo- 
sis, apart from lupus, seen in the living body. 

The virtual identity of the two diseases had, how- 
ever, already been suspected, for in 1874 Friedlander 
(Untersuchungen ueher Lupus, Virchow's Arch., Bd. 
60) maintained that they were identical processes, on 
the ground of like histologic structure. 

The later discovery of the tubercle bacillus, its dem- 
onstration in lupoid as well as in tuberculous tissue, 
and the results of inoculation tests definitely confirmed 
Friedlander 's suppositions. 



262 KASAL TUBEKCTJLOSIS. 

In 1877 Laveran (Un med. Nr., 35-63) described two 
cases of septal ulceration in patients with pulmonary 
and laryngeal tuberculosis, and microscopic examina- 
tion showed tubercles and giant cells in both instances. 

In the following year Riedel (Deutsche Zeitschr. f. 
CMr., Bd. 10) reported two additional nasal cases, both 
of which were apparently primary. 

An entirely new type of lesion was described by 
Thornwaldt in 1880 (Deutsche Arch. f. Klin. Med., Bd. 
77) : A man of 26 years, with hereditary taint, had 
tuberculosis of the lungs, larynx and pharynx, and the 
left nostril contained a small tuber cuius tumor on the 
anterior end of the inferior turbinate, and a similar 
but somewhat smaller growth on the floor of the nose. 
The posterior end of the septum was ulcerated and the 
mucous membrane over the cartilaginous portion was 
studded with granulations similar to those surrounding 
the tumors. 

That neither tuberculosis nor lupus was frequently 
recognized at this period, however, is witnessed by the 
writings of Michel, Frankel, and Mackenzie. 

Michel (Die Kranheiten der Nasenkolile, pg. 47, 
1876) claimed that he had never seen a case of ulcera- 
tion of the nose that was not dependent upon syphilis, 
while both Mackenzie (Diseases of the Nose and 
Throat) and Heryng (V. Zeims sen's Handbuch, Bd. 5, 
H. I.) asserted that they had never seen a single case of 
nasal tuberculosis. 

Additional cases by Tornwaldt (Deutsche Zeitschr. f. 
Klin. Mvd., Nr. 27, L880) ; WeichsQlbaum (Allg. Wien. 
Med. Ztg. Nr. 27-28, 1881); Milliard (Soc. Med. des 
Hop., L881) and Riehl (Wien med. Woch.Nr. 44, 1881) 



HISTORY. 26 



9 



were soon reported, but no case departing from the al- 
ready described types was recorded nntil Demme (Z. 
diagnost. Bedeut. d. Tuberhelbacillen f. d. Kindesalter, 
Berlin. Klin. Wochenschrift, Nr. 15, 1883), in a descrip- 
tion of two patients, drew attention to the occasional 
coincidence of tuberculosis and ozena. 

One of these cases, a child of twelve months, had 
"ozena scrofulosa," and later developed and died 
from pulmonary tuberculosis. 

The other, a baby of eight months, developed ozena 
two months after its adoption into a family the father 
of which had pulmonary tuberculosis. The septum 
showed a small ulcer surrounded by minute grayish 
yellow nodules. Death was due to meningitis tubercu- 
losa and autopsy proved all the other organs to be free 
from the disease. Bacilli and giant cells were found in 
the nasal mucosa. 

Before this communication, Volkmann (Tuberculose 
Erkrankungen der dem Chirurgen zugdnglich in 
Schleimhaute, Beiblatt. z. Centralbl. f. Chirurgie, Nr. 
24, and Centralb. fur Chirurgie, Nr. 3, 1882) had ad- 
vanced the theory of a tuberculous ozena dependent 
upon true tuberculous ulceration of the nose, and main- 
tained that it was absolutely distinct from the much 
more frequent "Bhinitis scrofulosa" which depended 
upon simple catarrhal inflammation. 

The fact that tuberculous fibromata are a frequent 
form of intra-nasal tuberculosis was brought forward 
by Konig in 1885, and his observations have been 
amply supported by subsequent statistics. 

So many cases were now recorded in quick succes- 
sion that by 1887 Cartaz (D. I. Tuberculose nas. France 



264 NASAL TUBEKCULOSIS. 

Medicale) was able to collect eighteen cases in addi- 
tion to one of his own. 

He classified nasal tuberculosis under two heads : tu- 
mor-like growths generally primary, and ulcers ; de- 
pendent usually upon preceding disease elsewhere. The 
two varieties may coexist. 

Two years later, Hajek (D. Tuber culose d. Nasen- 
schleimhaut, 1889) brought forward twenty-seven cases 
and added thereto three of his own, and in the follow- 
ing year Plicque found forty published cases. 

The latter author divided the tuberculous lesions into 
three groups : granulations, ulcerations and tumors. 

Heryng (Tuberculose d.Nasenschleimhaiit, 1892) as- 
sembled ninety cases, and in 1895 Stork (Die Erkank- 
ungen der Nase, Nothnagel's Spec. Path. u. Therapy, 
Bd. 13, 1 Theil) added twenty new patients. 

It can avail little to record all subsequent cases and 
while the number increases more rapidly as we become 
more diligent in studying all tuberculous patients, nasal 
tuberculosis can never be considered as other than the 
rarest form of infection in the respiratory tract. 

Up to this time no reference is found bearing upon 
tuberculous involvements of the accessory sinuses, but 
in 1889, Demme (27 Bericht des Jennerschen Kinder- 
hospitals, Bern.) reported an interesting case of maxil- 
lary sinus disease. In this case a nurse, who had a 
chronic dental fistula with purulent discharge and sep- 
tal lupus, was responsible for the development of fatal 
primary intestinal tuberculosis in four children, all of 
whom had non-tuberculous parents, through her prac- 
tice of tasting all Food before administering it to her 
charges. 



HISTOEY. 265 

Curettement and irrigations caused eventual healing. 

In the following decade a number of additional cases 
were placed upon record by Eethi (Wiener Med. Presse, 
May 7, 1893) ; (Ibid, No. 51, 1899) ; Maydl (Weiner Min. 
Wochenschrift, No. 51, 1899) ; Killian (Milnchener Med. 
Wochenschrift, No. 4, 5, 6, 1892); Zander (Empyema 
Antri Highmori Dissertatio, Halle, 1894) ; Newrnayer 
(Arch. f. Laryngologie, II, 1895) ; Keckwick (British 
Journal of Dental Science, May 13, 1895) ; Dmochowski 
(Arch. f. laryngologie, III, 1895) ; Griinwald (Die 
Lehre von dem Naseneiterungen, Munchen, 1896) ; E. 
Frankel (Virchoiv's Archiv. Vol. 143, 1896) and Gau- 
dier (Rev. Hehd. de Laryngol. No. 44, 1897). 

The cases of Gaudier and Keckwick were apparently 
of a primary nature. 

Involvements of the frontal sinus were recorded by. 
four observers only: Vohsen (Verhandlungen des X 
Inter nationalen Medizinischen Congresses, Berlin, 
1890, Vol. IV, Part 12) ; Franks and Kunze (Neiv York 
Medical Record, Nov. 3, 1894) ; Schenke (Dissertatio, 
Jena, 1898) and Pause (Arch. f. Laryngologie, XI, 
1901). 

The case described by Pause, in addition to the fron- 
tal and maxillary disease, had extensive involvement 
of the ethmoid and sphenoid cells. 

Halm (Ueb. Tuberculose d. Nasenschleimhaut, D. 
Med. Wochenschrift, Nr. 23, 1890) in accordance with 
the majority of clinicians, believed that the form of 
nasal lesion depended upon the type of infection, i. e., 
that the tumor represented a primary infection and 
that the ulcer was invariably secondary. 



266 NASAL TUBERCULOSIS. 

In the same year Olympitis grouped nasal tuberculo- 
sis according to the following types : 

1. Forme aigue. 

2. Forme chronique. 

1. F. chr. primitive : 

(a) variete polypoide. 

(b) variete infiltree. 

(c) ozene tuber culeux. 

(d) absces tuberculeux. 

sous-muqueux. 

2. F. chr. secondaire: 

(a) forme ulcer euse. 

(b) forme caseeuse. 

The acute miliary, the ulcerous, and the caseous va- 
rieties represent secondary, the remaining types, pri- 
mary infections. 

To this classification Gerber (Heymann's Handbuch 
der Laryngologie, 3 Band, 10 Lieferung, Seite, 915) 
made objection on the ground that only one case of 
acute nasal infection is recorded ; that the existence of 
an "ozena tuberculosa' ' is not indisputably proven, 
and because the types classed as "absces tuber culeux" 
and "forme caseeuse" are founded upon single obser- 
vations in each case and, moreover, that they are not 
distinct forms but merely subdivisions of clearly de- 
fined types. He substituted the following classifica- 
tion : 

1. The tuberculous ulcer. 

2. The tuberculous tumor. 
II. The diffuse infiltrate. | . 

4. The granulating type. ) ,jn P us - 



ETIOLOGY. 267 

Since the two conditions are practically identical, 
Massei (Revue hebdomadaire de Laryngologie, March 
11, 1905) proposed that the name lnpns be entirely 
done away with and that all the conditions coming un- 
der the two heads be known as tnbercnlosis. 

The last word upon this subject of differentiation, in 
which a position diametrically opposed to Massei's was 
taken, is quoted from the article by Henri Caboche 
which appeared in the Annales des Maladies de 
TOrville of October, 1907. 

He says: "We see then, to sum up, that there exist 
only two varieties of nasal tuberculosis : Miliary tu- 
berculosis with frank and unequivocal characteristics, 
and lupus which comprises : tubercular tumors and the 
majority of tubercular vegetations." 

' ' The facts seem to me clearly demonstrated : Under 
the names of tuberculous tumor, vegetating tubercu- 
losis and lupus, writers have described a sole and single 
thing. This identical thing should be called lupus, for 
it is characterized objectively and functionally by the 
same symptoms which, as I have shown already, char- 
acterize pituitary manifestations of those having skin 
lupus." 

ETIOLOGY. 

In view of the ubiquity of the tubercle bacillus, con- 
siderable numbers must occasionally be drawn into the 
nasal cavities of nearly all healthy individuals, and 
still more must this be the case with consumptives. 

Under normal conditions but few pass into the naso- 
pharynx and from there into the deeper parts of the 
respiratory tract, for the nose so perfectly performs its 



268 NASAL TTJBEECUL0S1S. 

function as a filter that only an exceedingly small pro- 
portion of the air-contained micro-organisms, no mat- 
ter what their character may be, penetrate beyond the 
introitus, and owing to some peculiar property of the 
nasal cavities and secretions, these rarely exert any 
baneful effects. 

That the mucus of a considerable percentage of heal- 
thy individuals contains bacilli has been shown by nu- 
merous investigators : 

Strauss examined the nasal secretions of 29 persons 
employed in rooms inhabited by consumptives, and 
found virulent tubercle bacilli in nine. 

Jones (Medical Eecord, Aug. 25, 1900) injected 
guinea pigs with mucus from the nostrils of average 
healthy persons not associated with consumptives, and 
had positive results in 10.3 per cent of the cases. 

Single bacilli must frequently be deposited upon the 
anterior part of the cartilaginous septum, the point 
where the inspired air first impinges, and particularly 
must this be the case in consumptives where, in ad- 
dition to the ordinary route of inhalation, they may 
be introduced by infected handkerchiefs and fingers. 

Despite the frequent deposit of bacilli at this point, 
however, and their proven ability to penetrate gland 
ducts and intact mucous membranes, infection is much 
rarer than in any other portion of the respiratory 
tract. The total number of cases recorded does not 
greatly exceed 150. 

In 1901 Knight was able to find but 108 reported 
cases. 

The relative proportion of nasal to pulmonary and 

laryngeal cases is shown in the following table: 



ETIOLOGY. 269 



Nasal 

Author Cases Tuberculosis 

Weichselbaum 146 consumptive cadavers.' 2 

Willigk 476 consumptive cadavers 1 

E. Prankel 50 consumptive cadavers 

Schmalf uss 1287 consumptives 

Henry Phipps Institute. . 389 consumptives* 

Steward 2777 nose and throat cases 3 

Gerber 1052 nose and throat cases 10 

Schaffer 450 nasal tumors 8 

Delavan 114 local tuberculosis i5 

Lockard 904 local tuberculosis 9 



7645 38 

*158 Laryngeal Cases. 

Thus, 3366 consumptives (672 cadavers) showed only 
17 cases of nasal tuberculosis, and among 4279 nose and 
throat cases there were but 21 with tuberculosis of the 
nose. 

Of the accessory sinuses, in so far as reliable statis- 
tics are available, the maxillary has been tuberculous 
some twenty-two times, the frontal cells in four cases, 
and the ethmoidal and sphenoidal combined in two 

cases. 

"While it cannot be denied that this form of infection 
is extremely rare, it is probably much less infrequent 
than these statistics indicate. 

The lesion may easily be overlooked because of its 
sluggish course and the greater importance of other 
symptoms, or it may be mistaken for , simpler condi- 
tions because of its obscure symptomatology and his- 
tory, yet despite the many probable omissions, nasal 
infection cannot be considered as other than the rarest 
form of respiratory tuberculosis. 

The deposit of bacilli has been shown to lessen prog- 
ressively from the nasal introitus to the lungs, yet the 
frequency of infection increases in inverse ratio : first 



270 NASAL TUBEKCULOSIS. 

the lungs, then the larynx, the pharynx, and finally the 
nose. 

Since infection is rarest at the point naturally most 
exposed to infection, one must assume for the nasal mu- 
cous membrane or its secretions some strong inherent 
power of defense, for the theory of an absence of pre- 
disposition to tuberculosis is untenable in view of the 
fact that a large number of individuals who successful- 
ly resist nasal infection fall prey to pulmonary tuber- 
culosis, and that in some of these patients nasal infec- 
tion occurs later on. 

What, then, are these means of defense? 

First in importance ranks the peculiar character of 
the nasal secretion which renders it antagonistic to the 
life or growth of morbific germs. 

Wiirtz and Lermoyez have shown that even the 
most resitant of anthrax spores are killed by the nasal 
mucus within three hours, and E. L. Shurly has proved 
that this antitoxic property is not peculiar to man but 
is also present in the mucus of monkeys. 

Liaras, and Park and Wright, do not fully accept 
these views as to the bactericidal power of the mucus 
but admit that it is an exceedingly poor culture medium. 

Experiments made by St. Clair Thompson and Hew- 
litt prove unmistakably that bacteria cannot thrive 
within the nostrils. In one group of experiments pure 
cultures of the Bacillus Prodigiosus were placed upon 
the anterior part of the septum, and after fifteen min- 
utes there was found to be a considerable diminution in 
the number of bacteria ; after eighty minutes none could 
be found and at the end of two hours no growth could 
he obtained in cultures. 



ETIOLOGY. 271 

In the second series a measured quantity of labora- 
tory air, containing 29 mould spores and nine bacteria, 
was passed through the nose and measured as it passed 
through the choanae, and was found to have lost all but 
two of the mould spores and all of the bacteria. 

Piaget claims that the nasal mucus is absolutely fatal 
to the anthrax bacillus, the diphtheritic bacillus, the 
colon bacillus and some forms of the streptococcus 
and staphylococcus. 

The second barrier is formed by the extreme sensi- 
tiveness and reflex irritability of the nasal mucous 
membrane, whereby the inhalation of any irritant pro- 
vokes almost instantaneous congestion, swelling of the 
erectile tissues and increased flow of the watery se- 
cretions, with probable expulsion of the foreign ele- 
ment. If this proves ineffectual the resultant sneezing 
and blowing of the nose aid in cleansing the tissues. 

The normal flow of the secretions from the roof of 
the nose downward, and either to the anterior or pos- 
terior openings, carries with it nearly all of the ex- 
traneous substances, and in this cleansing action the 
cilia take part. 

The bacilli find additional obstacles to premanent 
lodgement in the constant presence of a film of protec- 
tive mucus, in the filtering functions of the vibrissae 
and in the character of the tissues at certain points, 
i. e., squamous epithelium. 

This combination of defensive agencies is generally 
sufficient to repel any injurious invasion but it may 
prove unavailing, first, when large numbers of bacilli 
are introduced at one time and secondly, when by 
reason of previous or simultaneous disease, or trauma- 



272 NASAL TUBERCULOSIS. 

tism, one or more of the barriers are weakened or de- 
stroyed. 

Demonstrating the effect produced by the simultan- 
eous introduction of a large number of bacilli, the fol- 
lowing experiments may be cited: 

De Bono and Frisco (Annali cV Igiene 8 per., 1901- 
03) produced tuberculosis in guinea pigs by inoculation 
with the aqueous humor of the eyes of rabbits, aspi- 
rated one hour after pure cultures of tubercle bacilli 
were brought into contact with the nasal mucous mem- 
branes. 

Eenshaw (Journal of Pathology, 1901), by applying 
bacilli to the uninjured nasal mucosa, produced tuber- 
culosis of the lymphatic glands in seven of eight cases. 

Cornet obtained similar results, introducing the 
bacilli upon a pigeon feather in order to avoid trauma- 
tism. 

While, in rare instances, the bacilli may penetrate an 
intact epithelial surface, some previous disease or trau- 
matism is usually essential. Perhaps the most fre- 
quent contributory factor is the condition known as 
Xanthosis. The inspiratory air current first strikes 
the cartilaginous septum and there deposits a consid- 
erable part of its contained dust and micro-organisms. 
The irritation from, and the separation of, this dust 
scab produce erosions, with hemorrhage and degenera- 
tion. In many cases the traumatism results from for- 
cible blowing or picking of the nose and these habits 
are therefore especially reprehensible in consumptives. 
It is upon this spot thai nasal tuberculosis usually orig- 
inates. 



ETIOLOGY. 273 

Both the nicer and tnmor occnr most frequently 
within this damaged area; in Steward's collection of 
100 cases the septum was attacked in 89 per cent, and 
was the sole nasal localization in 70 per cent. 

The traumatism may result in subsequent inhalation 
infection or what is more probable, simultaneous in- 
fection by means of bacilli already present in the nose 
or deposited soon afterward by infected finger-nails 
and handkerchiefs. Schmitthuisen (Journal of Laryn- 
gology, Pg. 397, 1900) and Kiar (Rev. de Laryngol., 
Pg. 263, 1901) have recorded cases which seem to have 
been produced in this way, and Schech (Kranhheiten 
der Mundhohle, Pg. 316-317, 1896) describes the case 
of a woman who acquired nasal tuberculosis by using 
the unwashed handkerchief of her tuberculous husband. 

It is a common practise to ascribe to catarrh a promi- 
nent place in etiology because of the resultant abra- 
sions and lessened vitality of the mucosa. It has been 
conclusively demonstrated, however, that catarrhal in- 
flammations markedly reduce the absorptive properties 
of the tissues and this factor, in connection with the 
diminished caliber of the nasal cavities and the greatly 
increased flow of mucus, may fully counteract the ef- 
fect of the surface erosions. 

Halm has recorded a case of tuberculous tumor in a 
patient who had a long standing eczema of the upper 
lip and nose. 

Primary and Secondary Infection : — Tuberculosis of 
the nose may be either primary or secondary, the lat- 
ter representing the more frequent form of the dis- 
ease. This is what would naturally be expected from 
a study of the predisposing causes. 






274 NASAL TUBEKCULOSIS. 

Aside from the not infrequent conveyance of infec- 
tion through the lymph channels and blood current, the 
careless consumptive is constantly exposed to the dan- 
ger of auto-infection by unclean fingers, linen, spray 
tubes, &c. 

Suppressed coughing or violent attacks of retching 
and vomiting may likewise carry virulent colonies of 
bacilli into the nasal cavities, and their susceptibility 
to large numbers of bacilli simultaneously introduced 
has already been shown. 

The introduction of bacilli into the nose by incom- 
pletely expectorated sputum was claimed by Kossel to 
be responsible for the numerous tubercle bacilli found 
in the nasal mucus of a young girl dead of pulmonary 
and cerebral tuberculosis. The nasal mucous mem- 
branes were found at autopsy to be entirely normal. 

In consumptives we also find an occasional trans- 
ference of the disease from neighboring structures to 
the nose. Newmayer (Arch. f. Laryng., Bd. II, 2 Heft, 
5260, 1894) records a case in which the nasal lesion 
could be traced back through the maxillary sinus to a 
buccal tuberculosis, consequent upon the extraction of 
a tooth. A similar case is recorded by Rethi (Wien. 
Med. Pr. 19, 1893). 

Infection may also occur through palatal perfora- 
tions (pg. 357). 

The comparative frequency of primary and second- 
ary cases depends upon the interpretation of the terms 
"primary" and "secondary." 

If by primary disease is understood all cases in 
wlii el i at the lime the nasal lesion becomes manifest no 
other focus is clinically demonstrable, the dispropor- 



ETIOLOGY. 275 

tion between the two types is not great, bnt as is the 
case with the larynx, the primary natnre of a lesion 
cannot be definitely proven except upon the cadaver. 

Apparently sonnd individnals may conceal latent 
foci that nnder the influence of tranma will give rise to 
disseminated infections, that may to all appearances be 
primary localizations. 

The apparently primary lesion, however, is not un- 
common. Herzog (Amer. Journal of Med. Sc, Dec, 
1893) assembled twenty primary cases to sixty of a 
secondary nature, and in 1890 Olympitis (Tubercul. d. 
I. muqueuse. nas. These, Paris) found nineteen cases of 
primary and four of possibly primary origin in a 
total of thirty-nine cases. 

Beermann (Ueb. prim. Tuherc. d. Nasenschleimh. 
Diss., Wurzburg, 1890), of twenty-nine cases collected 
by him, considered ten as probably primary. 

Sixteen of twenty-one cases reported by Chiari were 
primary, and in Steward's collection of one hundred 
cases, fifty-eight appeared to be primary. 

On the other hand, Gonguenheim and Glover {Atlas 
de Laryngologie et de Rhinologie) consider the greater 
number to be secondary. 

Of eight cases of tuberculous nasal tumors «°en by 
SchafTer, none had other demonstrable signs of the 
disease. Chiari (Ueb. Tuber culome d. Nasenschleim- 
haut, Arch. f. Laryngologie, 1893, Bd. I, Heft, II, 8, 
121) assembled a total of twenty-one cases of which 
the following classifications was made : 



276 NASAL TUBEKCULOSIS. 

CASES' 21. 

Pulmonary Tuberculosis 5 cases. 

Scrofulous or hereditary taint 7 cases. 

No demonstrable pulmonary disease 13 cases. 

Evident infection from without 6 cases. 

Bacilli found in 11 cases. 

Histologic diagnosis in 6 cases. 

Clinical diagnosis only 4 cases. 

In twenty- two cases of maxillary sinus tuberculosis, 
three (Gaudier, Coakley, Keckwick) were without other 
evidences of the disease. 

We are yet in the dark regarding the modus operandi 
by which lupus results in one individual and tubercu- 
losis in another. 

Lupus, in contradistinction to tuberculosis, is always 
a local disease, the result of direct infection of an 
abraded skin or mucous membrane and in a large ma- 
jority of the cases seems to be dependent upon the ex- 
istence of a strongly marked tuberculous diathesis. 

According to Moure it often follows a strumous 
pseudo-atrophic coryza. 

Sachse (Beitrag. zur Statistick des Lupus, Viertel- 
jahrisch.. f. Derm. u. By ph., Bd. 13, 8. 241) found defi- 
nite signs of tuberculosis or hereditary tendency in 
55.89 per cent of all cases ; Demme in 37.2 per cent and 
Bloch in 25.5 per cent. 

Bender (Ueber die Beziehungen des Lupus vulg. zur 
Tuberculose, Bed. Klin. Woch., Nr. 23-24, 1886), in 
L59 lupoid patients, found definite signs of tuberculosis 
in 109, while Raudnitz found only ten per cent with 
hereditary taint. 

I' locli claims that three-fourths of all lupoid patients 
show oilier signs of tuberculosis, and he saw eight of 
nine such individuals die of pulmonary tuberculosis. 

Sachse saw a similar resull in six or seven patients. 



lupus. 277 

From a study of a large series of cases Caboche ar- 
rives at the following conclusions : "Ina certain num- 
ber of cases the lupus patient does not get well and 
dies of pulmonary tuberculosis. I have seen this event- 
uality once. Thus, while the patient with pulmonary 
tuberculosis never, so to speak, becomes lupic, the re- 
verse is far from rare. (Lenglet)." 

Primary lupus of the mucous membranes is compara- 
tively frequent, although it is usually secondary to lu- 
pus of the skin. 

CASES OF LUPUS. 

Primary in 
Observer Nasal Mucosa 

Caboche 22 

Raudnitz 4 

Pontoppidan 100 

Cozzolino 5 

Bloch 10 

Bender 75 

Mummenhoff 37 

Total 253 

Many of the more recent observers (Escat, Bresgen, 
Chiari, Audry, Sticker, Caboche) believe that the ma- 
jority of cases of facial lupus are secondary to lesions 
of the mucosa, unobserved because of their sluggish, 
symptomless course, and transmitted through the lym- 
phatic system. 

SEX AND AGE. 

Nasal lupus occurs most frequently in women. 

Observer Men Women 

Raudnitz 37.7 % 62.7 % 

Pontoppidan 34.0 % 66.0 % 

Bloch 31.9 % 68.1 % 

34.4 % 65.6% 



278 NASAL TUBERCULOSIS. 

In twenty personal cases of Caboche, eighteen were 
women and two men. 

The relationship is practically the same as in nasal 
tuberculosis. 

Steward in 100 cases found 41% 59% 

Stork in 20 cases found 20% 80% 

A comparative study shows: 

Lupus 34.4% 65.6% 

Tuberculosis 30.5% 69.2% 

The age incidence in nasal and laryngeal tubercu- 
losis varies but little. 

OZENA AND TUBEKCULOSIS. 

While not strictly related to the question of the 
etiology of nasal tuberculosis, the relationship of nasal 
atrophy to pulmonary tuberculosis is of sufficient im- 
portance to merit brief comment. 

Demme (Z. diagnost. Bedeut. d. Tuberkelbacillen /. 
d. Kinder Salter, Ber. Klin. Woch., Nr. 15, 1883) first 
drew attention to this relationship by his report of a 
case of a twelve months old baby that suffered from 
"ozaena scrofulosa," which later developed and died 
from pulmonary tuberculosis. Since this report the 
relationship has been frequently observed and com- 
mented upon. 

Freudenthal, in an examination of 340 patients of 
the Bedford Sanatorium for Consumptives (N. Y. Med. 
Journ., Dec. 19, 1903), found that 115 had a dry condi- 
tion of the nose or a genuine atrophic condition, and 
readied the conclusion that, "the dry atrophic condi- 
tion of the nose and throat produced by our unhygienic 
system of heating is one important factor in laying the 
foundation for tuberculosis." 



OZENA. 279 

Clark found some evidence of a nasal atrophy in 73 
of 170 phthisical patients, and J. K. Hamilton, in 170 
cases of ozena, found six with phthisis. A. Alexan- 
der (Arch. f. Laryngologie, B. 14, H. 2) found 31 cases 
of atrophy in 200 consumptives and 22 cases of tuber- 
culosis in 50 ozena patients. Of the remaining 28 
ozena cases, four had other diseases of the lungs and 
seven were classed as " suspicious. " 

In 22 autopsies upon ozena patients, phthisis was 
demonstrated in 15. 

Three hundred and eighty-nine consumptives of the 
Henry Phipps Institute (Second Annual Eeport) 
showed six with nasal atrophy. 

C. H. Theisen (Laryngoscope, Oct., 1904) reported 
40 personal cases of ozena ; of these 14 had well 
marked pulmonary tuberculosis. 

Liaras (These de Bordeaux, 1899) found but two 
cases of tuberculosis in 52 of ozenatous rhinitis. 

The author, in 275 consumptives, met with 49 cases of 
nasal atrophy. 

A summary of these reports shows : 

1304 Consumptives 274 cases of atrophy 20.25% 

312 Ozena cases...- 44 consumptives 14.1% 

These statistics make the conclusion irresistible that 
ozena predisposes to tuberculosis, although the fact 
must not be lost sight of that in some of these cases 
the converse may obtain, i. e., the malnutrition ante- 
dating the development of tuberculosis or following its 
advent, may provoke the intra-nasal degeneration. 

It has been shown that the nasal mucous membrane 
and its mucus have certain properties that render the 
nose unfavorable to the lodgment and development of 



280 NASAL TUBEKCULOSIS. 

morbific germs, and it is evident that these barriers 
are absolutely destroyed by ozena. As Alexander 
says: "The nose, or the filter which shonld protect 
the body from the bad results of the invasion of micro- 
organisms, itself becomes a permanent source of in- 
fection. ' ' 

Whether or not there is a form of nasal tuberculosis 
worthy of the designation ozenous is disputed but a 
careful examination of the so-called confirmatory cases, 
together with certain theoretical considerations, would 
tend to the belief that in these patients there has been 
merely an accidental association of the two conditions, 
rather than that the ozena depended upon the presence 
of the tubercle bacilli. 

In the few authentic cases recorded in which ozena 
accompanied tuberculous lesions, the latter were inva- 
riably in the form of numerous minute ulcers and since 
it is a well substantiated fact that ulcerations never oc- 
cur in true atrophic rhinitis, the belief is warranted 
that in these patients the tuberculosis was grafted upon 
tissues already affected by true ozena. 

If the bacilli were capable of provoking ozena, is it 
not surprising, in view of the large number of carefully 
observed cases of nasal tuberculosis, that not more 
than three cases have been observed in which this symp- 
tom was present? 

It has been shown that over 20 per cent of all con- 
sumptives, studied with a view of determining the re- 
lationship between atrophy and pulmonary tuberculo- 
sis, have shown such a condition of the nasal mucosa, 
lieiiee we have all the conditions most favorable for 



PLATE XVII. 



Fig. 65. Incipient tuberculosis of the nose, involving the 
anterior end of the inferior turbinate, the 
quadrangular cartilage and floor. 

Fig. 66. Tuberculous infiltration and ulceration of the 
posterior portion of the septum and of the 
pharyngeal tonsil. 



PLATE XVII. 

Fig. 65. Incipient tuberculosis of the nose. 

Fig. 66. Tuberculosis of the posterior septum and the 
pharyngeal tonsil. 





Fig. 65. 




Fig. 66. 



PLATE XVII. 



OZENA. 281 

infection by both the micro-organisms of ozena and 
the bacillus of tuberculosis. 

SYMPTOMATOLOGY. 

Tuberculosis of the nose usually becomes manifest 
either as a tumor or an ulcer but in very rare instances 
it may be seen in the stage of circumscribed or diffuse 
infiltration. 

The diffuse infiltrate, however, can scarcely be looked 
most frequent manifestation of lupus and is generally 
upon as a typical lesion, because in the nose it is the 
indicative of a lupoid rather than of a true tuberculous 
infection. The same may be said of the granuloma. 

The ulcer is invariably found in individuals already 
suffering from other and well-advanced tuberculous 
processes, usually of the lungs, or lungs and larynx, 
but the tumor is not infrequently the first and only 
recognizable focus. 

The tumor occurs less frequently than the ulcer al- 
though the disparity is not great : the former was met 
42 times and the latter 48 times in a total of 90 cases. Of 
20 cases seen by Storck, 6 were tumors and 14 ulcers. 

As has already been shown, however, both conditions 
are extremely rare, but 14 cases having been seen in 
2694 consumptives, while examination of 672 tubercu- 
lous cadavers revealed but three tuberculous lesions of 
the nose. 

Systematic examination of every consumptive would 
without doubt materially increase the percentage of 
cases (one case in every one hundred of laryngeal tu- 
berculosis was seen by the author) for in but few pa- 



282 NASAL TUBERCULOSIS. 

tients are the evoked symptoms sufficient to occasion 
comment, especially when the pulmonary and laryngeal 
foci are far advanced. 

The forms designated as nodular, vegetating, and in- 
filtrative, because they conform to the appearances 
usually found in association with facial lupus, are 
frequently classed as lupic rather than as tuberculous, 
but as the various types frequently coexist and are to 
all intents identical processes, they will be so consid- 
ered and grouped under the common name of tubercu- 
losis. No attempt at strict differentiation will be made, 
for it can lead only to confusion except in the question 
of prognosis, where the lesions of a definite lupic char- 
acter certainly offer a more hopeful prospect than those 
which conform to the appearances of tuberculosis seen 
elsewhere. 

THE TUMOE, 

The tumor, like the ulcer and the infiltrate, attacks 
by preference the quadrangular cartilage but in rare 
instances may be primarily situated upon one of the 
turbinal bodies or the floor of the nose. 

When the middle turbinate is involved the case is 
exceptional, and the inferior body is the primary site 
in not more than one case in four or five. Invasion of 
the nasal floor almost never occurs except through ex- 
tension from the septum or the turbinals and either of 
these parts may be involved by the process spreading 
across the floor from one side to the opposite one. 

Mcn-icr ( Revue hebdomadaire de Laryngologic, June 
14, 1902) observed a case of tuberculoma in which the 
posterior end of the septum was alone involved. 



OBJECTIVE SYMPTOMS. 283 

When extensive distribution has once occurred, the 
point of origin can rarely be determined. 

The tmnor, like its laryngeal prototype, may be 
single, as is usually the case, or there may be two or 
more. Many eases classified as tumors have probably 
not been such at all if the term be understood to desig- 
nate only those growths that are not preceded by ulcer- 
ation. 

Particularly is this the case with multiple growths, 
unless they are sharply defined and separated by areas 
of normal tissue, for the majority of these tumors are 
merely masses of exuberant granulations springing 
from and completely hiding underlying ulcers. 

The true tuberculoma varies in size from a pea to a 
small, chicken's egg y and while it is generaly a solid 
growth it may be composed of a number of firmly 
united nodules of small size. The mass is round or ir- 
regular in form and usually sessile, although not in- 
frequently pedunculated. 

The latter type, when covered by a smooth mucosa, 
grayish or grayish-red in color, bears some resemblance 
to a fibroma. The color may vary from this transpar- 
ent gray to a purplish red and the mucous membrane, 
instead of being smooth and glistening, may be granu- 
lar or even warty. The surface is sometimes traversed 
by prominent blood-vessels. 

The growth is generally insensitive and bleeds freely 
on gentle manipulation. 

Free bleeding occurs nearly always with tumors that 
are soft and friable, although a case is recorded by 
Halm in which easily provoked hemorrhages occurred 



284 NASAL TUBEKCULOSIS. 

from a growth that was of an unusually firm consist- 
ency. 

The tuberculoma is generally unilateral in the begin- 
ning but as time passes, if it be located upon the sep- 
tum, the dividing wall gives way and a homogeneous 
mass protrudes into both nostrils. Although in cases 
of long standing there is practically always ulceration 
within or about the base of the tumor, involving, per- 
haps, the entire cartilaginous septum in the destruct- 
ive process, the surface may and generally does main- 
tain its integrity for a long time. 

When ulceration does begin upon the surface tbe 
entire growth melts away with great rapidity and the 
nostril, for the time being, may be entirely occluded by 
the exuberant granulations. These in turn succumb to 
the destructive process and soon all evidences of the 
tumor formation may have vanished, leaving no visible 
signs aside fom the great, and more or less distinctive, 
septal destruction. 

Miliary tubercles are often seen about the circum- 
ference and they occasionally dot the entire surface of 
the growth. 

Instead of one primary growth there are sometimes 
two or more small tumors, occupying different parts 
of the cartilaginous septum, and each may lead to a 
distinct perforation. 

The subjective symptoms are slight and frequently 
masked by those consequent upon the pulmonary or 
Laryngeal lesions. In the beginning there is nothing 
more than partial nasal obstruction which remains un- 
accompanied by other symptoms until some superfi- 
cial ulceration occurs, when the nasal secretions become 



OBJECTIVE SYMPTOMS. 285 

purulent and somewhat foul. In such cases bleeding 
occurs at intervals and there is considerable scab for- 
mation. 

Alterations in the shape of the exterior nose have 
not been observed except in rare cases. Schaffer re- 
ports one in which there was a warty thickening of the 
entire organ. 

Both the tumor and the ulcer may, exceptionally, 
produce a palatal perforation ,or extensive necrosis of 
the nasal bones, with a sinking-in of the bridge, the so- 
called "saddle nose." 

The majority of these cases of so-called tuberculous 
tumors, 44 in all, are classed by Caboche as lupus, on 
the ground that they occurred in patients free of pul- 
monary disease and on section usually failed to reveal 
bacilli. He considers 29 of these growths to be purely 
lupic. 

THE ULCER. 

Although the appearance of an ulcer is nearly al- 
ways preceded by a stage of infiltration, variably long, 
this antecedent condition is almost never seen because 
of the few subjective symptoms evoked. 

Many authors speak of a " primary "■ ulcer. Thus 
Gerber (Handbuch der Laryngologie und Rhinologie, 
1899, page 916) says: 

"The tuberculous nasal ulcer is very rare. I have 
seen it several times in consumptives. Frequently 
enough, however, there is ulceration of the infiltra- 
tions and granulations." 

Although the occurrence of ulceration without pre- 
ceding infiltration has been repeatedly affirmed, I be- 
lieve that there can be no question that every tuber- 



286 NASAL TUBEKCTJLOSIS. 

culous ulcer occurs upon an infiltrated tissue. We may 
here, as in the larynx, have a bacillary infection of a 
simple ulcer but the so-called true ulcer results from 
caseation of submucous tubercles. 

Owing to the rapid destruction when necrosis has 
once begun, it is unusual to find evidences of preceding 
infiltration, but this has occasionally been observed. 

The early infiltrate may be covered by a smooth, or 
what is far more frequent, a nodular mucosa; the lat- 
ter may be of a simple granular character or so infil- 
trated by large tubercles as to be distinctly warty. 

The swelling is hard and fairly resistant, and as 
there is little attendant inflammation the color does 
not depart far from the normal : it is usually a pale red. 
AVitli profuse nodule formation the tissue becomes 
soft and compressible. (Plate XVII, Fig. 65.) 

While the septum is the preferred point of attack, 
the turbinals are occasionally primarily involved. The 
septal swelling may be circumscribed or so diffuse as to 
involve the entire cartilaginous portion; in the latter 
instance ulceration rapidly ensues with multiple perfo- 
rations and wide destruction. 

When the nostril is filled with exuberant granula- 
tions the almost typical picture of a large tumor is 
presented. Schech stands alone in describing the 
lesions as poor in granulation tissue (Krankheiten der 
Mundhohle, pg. 317). 

The ulcer in its earliest stages is rarely seen owing 
to ils unobtrusive symptoms and their complete mask- 
ing by those dependent upon more important lesions. 

A.s the anterior part of the quadrangular cartilage is 
the elective point for the infiltrate and tumor, it is con- 



PLATE XVIII. 



Fig. 67. Incipient tuberculosis of the inferior turbinat< 
and meatus. 



PLATE XVIII. 



Fig. 67. Tuberculosis of the inferior turbinate and meatus. 




Fig. 67. 



PLATE XVIII. 



OBJECTIVE SYMPTOMS. 287 

sequently the point at which ulceration most often 
occurs. 

The reason for this localization has already been 
shown to depend upon traumatism and it is at the same 
point that other traumatic lesions occur, i. e., simple 
perforating ulcers, occupation necrosis, &c. 

From this elective point the process extends across 
the nasal floor to one or both turbinals, but the transfer- 
ence may occur in the opposite direction from an orig- 
inal focus upon either the inferior or middle turbinal. 
(Plate XVIII, Fig. 67.) 

Pluder (Zwei BemerJcensiu. Falle v. Tuberculose d. 
obersten Athmungsw., Arch. f. Laryngologie, Bd., IV, 
I Heft, 8. 117, 1896) described a case seen by him in 
which there was widespread ulceration of the posterior 
edge of the septum and exuberant granulations cover- 
ing the floor of the nose. In this case the infection oc- 
curred through a cleft palate. 

Grerber also described a case in which there was wide 
involvement of and about the choanae. There were 
numerous miliary tubercles on the vault of the pharynx 
and the posterior openings were almost obliterated on 
both sides, on the right by a homogeneous mass, on the 
left bv two distinct tumors. On each side the swelling 
seemed to spring from the posterior turbinals. The 
right tube was entirely involved and the left was enor- 
mously enlarged and covered with papillomatous ex- 
crescences. 

Springing from the upper edge of the choana and 
filling the space between the lateral tumors was a pale 
teat-like projection of tissue resembling the uvula. The 
cervical glands were tuberculous and after their ex- 



288 NASAL TUBEKCULOSIS. 

cision the naso-pliaryngeal and nasal process rapidly 
retrogressed, with the expulsion of a large sequestrum 
from the posterior edge of the septum. There was 
eventual healing. 

This case is somewhat similar, although much more 
extensive, to one seen by the author in 1902, which like- 
wise resulted in complete local healing. This patient, 
a young man of 23 years, had had advanced pulmonary 
tuberculosis for over two years and at the time of first 
examination had suffered for several weeks from se- 
vere symptoms referable to the naso-pharynx. Pos- 
terior rhinoscopy showed a deep ulcer, about the size 
of a ten-cent piece, immediately above and between 
the choanae, surrounded by numerous miliary tu- 
bercles and small granulations. The surrounding mu- 
cous membrane was considerably inflamed. From the 
lower edge of this oval ulcer, at about the middle point, 
a narrow, irregular groove extended down the posteri- 
or edge of the septum to a point slightly above the low- 
er border. The mucous membrane projected into the 
nostrils from each side of the septum and diminished 
the normal diameters by about one-half. (Plate XVII. 
Fig. 66.) As soon as possible all the diseas- 
ed tissue was curetted and thoroughly cauter- 
ized, and in two months every evidence of the dis- 
ease had disappeared. He lived for fourteen months 
and had no recurrence. 

The involvements of the posterior septum and tur- 
binals may originate at these points or extend to them 
Prom contiguous portions of the nose, naso-pharynx 
or palate. 

The ulcer, when not hidden by granulations, may 



OBJECTIVE SYMPTOMS. lo-J 

have the so-called typical tuberculous characteristics, 
but on the other hand, owing to frequent bleeding, and 
irritation and discoloration by the air currents and 
dust, it may lose these pathognomonic features and be 
recognized with difficulty. 

In the unaltered type we find the same mouse-eaten, 
irregular edges, uneven base, superficial involvement 
and grayish or yellowish white discoloration that has 
been noted in the laryngeal ulcers. Miliary tubercles 
are occasionally seen in the neighboring tissues and 
granulations are always present, either projecting from 
the membranous base or surrounding the ragged edges. 

These small projections are generally hidden by a 
deposit of tenacious muco-pus and come into view only 
after careful cleansing. 

The edges may be considerably undermined and 
prominent, or even clear cut and infiltrated, and in ex- 
ceptional cases they merge by gradual transition into 
an inflamed areola. In some instances the base is per- 
fectly even and appears to be slightly elevated, as 
though there were a deposit of false membrane. This 
is due to the breaking down of a tissue already con- 
siderably infiltrated. 

The ulcers are usually solitary and of variable size 
and shape — round, oval, serpiginous or irregular. 

Two or three separate ulcers occur in some rare 
cases and a few instances of numerous small ones, dot- 
ting the entire septal mucosa, are recorded. 

The individual ulcers enlarge through disintegration 
of surrounding miliary tubercles and the confluence of 
contiguous spots. 



290 NASAL TUBEKCULOSIS. 

In many cases the initial lesion, whether it be an ul- 
cer, infiltrate or tumor, is entirely hidden by the ac- 
companying granulations, and as already mentioned, 
these may attain such size and consistency as to closely 
resemble tuberculomata. As diffuse granulations are 
almost pathogonomic of lupus, the differential diag- 
nosis, when the nasal lesion is primary, may be ex- 
ceedingly difficult. 

In certain cases, classed usually as lupic, the mu- 
cosa is widely studded with small, soft nodules, sepa- 
rated one from the other by irregular grooves and ul- 
cers ; in other instances the membrane is extensively 
thickened with uneven projections and depressions 
which Caboche describes as follows : * ' One sees minute 
hillocks separated by miniature valleys. Each of the 
hillocks, sometimes rounded like a dome, sometimes 
terminating in a sharp crest, is made up (the same as 
the valleys) of an agglomeration of very small nodules 
the size of a pin head, separated by extremely narrow 
grooves, giving to the lesion as a whole a muriform 
aspect which is peculiar to it." 

The subjective symptoms are not marked: there is 
usually slight respiratory obstruction, scab formation 
and sporadic attacks of bleeding. Pain is not severe 
and often entirely lacking, and is prominent only when 
the skin border becomes involved, upon extension of 
the process to the perichondrium and in cases of acute 
miliary infection. 

Lupus runs a painless course. 

Practically all cases advance gradually to perichon- 
dritis and chondritis, through direct extension. Pri- 
mary infection of the bone or cartilage, on flu 4 other 



OBJECTIVE SYMPTOMS. 291 

hand, is exceedingly rare. Two such cases have been 
recorded but in neither was the evidence conclusive. 

Perforation of the nasal septum is much more fre- 
quent in consumptives than in individuals otherwise 
normal and while the greater number of these are of 
simple traumatic origin, a certain proportion depend 
upon tuberculosis; the edges are not smooth and thin 
as in the simple variety but enormously thickened, 
warty and granular. They bleed easily upon manipu- 
lation and are generally covered by tenacious scabs 
of mucus, pus, blood and epithelial cells. 

Weichselbaum claims that septal perforations are 
found twice as often in consumptive as in non-tubeeu- 
lous cadavers. 

According to D. Braden Kyle, septal perforations oc- 
cur in the proportion of one to every 200 cases of nasal 
disease, but in the author's series of 904 cases of laryn- 
geal tuberculosis, there were 36 with this condition or 
one in every 25. 

ACCESSOEY SINUSES. 

As indicated in the Historical review, tuberculosis 
of the accessory sinuses is a relatively rare condition, 
the total number of verified cases not exceeding twenty- 
seven. To this total the maxillary sinus contributed 
twenty- two; the frontal cells, four; and the ethmoidal 
and sphenoidal combined, two, one of which is included 
among the frontal cases as all four sinuses were in- 
volved. 

Suppurative sinusitis occurs frequently in phthisical 
patients as is shown by the following table, but there 
are no figures to indicate how many were tuberculous 
and how many non- tuberculous. 



292 NASAL TUBERCULOSIS. 



Tuberculosis Sinus 

Author Publication Cadavers Disease 

Lapalle Arch. Internat. de Laryngcl, 

May-June, 1899 59 19 

Wertheim Arch. f. Laryngologie, 

XL 1906 106 31 

Minder Ibid. XII, 1902 17 4 

E. Frankel Virchow's Archives, 

Vol. 143, 1896 48 9 

Dmochowski Arch. f. Laryngologie, 

III, 1895 29 * 3 

Oppikof er Ibid. XIX, 1906 51 25 



310 91 

*Max. Sin. 

It is probable that the great majority of these cases 
did not depend upon the presence of the tubercle bacil- 
lus. 

Ingersoll and Howard examined a number of cases 
of chronic suppuration to determine their relationship 
with tuberculosis but did not find the bacilli in a single 
instance. In collaboration with Dr. Carmody, the au- 
thor has examined eight cases of sinusitis occurring 
in consumptive patients without finding the bacilli in 
one. 

In one post-mortem case, Frankel found bacilli in 
a maxillary sinus where tuberculosis had not been diag- 
nosed during life. 

Prom an exhaustive study of twenty published cases 
of maxillary sinus tuberculosis, Gleitsmann, in an ar- 
ticle read before the Twenty-ninth Annual Congress 
of the American Laryngological Association, drew the 
following conclusions as to their causation: 

"From the histories furnished, we learn, what is to 
be expected, viz.: that the majority of sinus. tubercu- 
losis is due to an extension from a neighboring tuber- 
culous focus. Of the twenty cases of tuberculosis of 
the maxillary sinus, which I could find, twelve were 



ACCESSOKY SINUSES. 293 

due to tubercular lesions of the bones of the nose or 
upper maxilla, whilst in the remaining eight, carious 
processes of these parts can be excluded. The majority 
of patients suffered from pulmonary tuberculosis, and 
a few only had the well-known symptoms of antral em- 
pyema without any constitutional disturbances, but at 
operation tubercle bacilli were found in the discharge 
evacuated. In eight instances the presence of tubercle 

bacilli in the antral secretion was verified by micro scop- 

* 

ical examination." 

In five of these twenty cases the disease reached the 
sinus by extension from a focus in the alveolar process 
through a dental fistula. 

A case in which the infection travelled in a direc- 
tion directly opposite to this last described channel 
was recently seen by the author in consultation with 
Dr. Carmody. 

This patient, a cigar maker, had had pulmonary tu- 
berculosis of several years' duration when the left 
maxillary sinus became involved. This had been neg- 
lected until, after a number of months, pain developed 
in the incisor with necrosis of the root and loosening 
of the tooth. The tooth was extracted but shortly 
afterward a fistula developed and nearly a year elapsed 
before a cure was effected. The fistula opened above 
the incisor and extended back of the bicuspid. Tubercle 
bacilli were not found but the opening in the alveolus 
was typically tuberculous, as is shown in Fig. 68 and 
Plate XIX, Fig. 69. 

In two of the twenty cases detailed by Gleitsmann 
infection came from a nasal lupus, in one it occurred 



294 



NASAL TUBERCULOSIS. 



through the canine fossa. In all but three of the cases 
there was pulmonary phthisis. 

As a rule it is impossible to demonstrate the presence 
of tubercle bacilli but this has been done in a small 
number of instances. 

Four cases of frontal sinus tuberculosis have been 
recorded; in three the frontal was the only cell in- 
volved, in one all four sinuses were affected. 






Fig. G8. 

These cases were observed by Pause, Franks and 
Kunxe, Vohsen, and Schenke. 

KHienke's case, as described by Gleitsmann in the 
address already referred to, concerned a man IS years 
of age who had tuberculosis o\' the middle ear and 
cervical glands. "When admitted to the hospital lie 
had a swelling of the frontal region and a fistula of the 



PLATE XIX. 



Fig. 69. Perforation of the alveolus due to a tuberculous 
maxillary empyema. 

Fig. 70. Tuberculous ulceration of the tuberosity. 
(Illustrations used by courtesy of Dr. T. E. Carmody.) 



PLATE XIX. 

Fig. 69. Perforation of the alveolus. 
Fig. 70. Ulceration of the tuberosity. 



1 




Fig. 69. 



C^\st*K\— i— >r^~ cj -si 




1 



Fig. 70. 



PLATE XIX. 



ACCE3S0EY SINUSES. 295 

mastoid process, extending posteriorly towards the 
cranial basis, and another one leading to the styloid 
process. A few days after the fistulous dncts had been 
scraped, the frontal sinns was operated, and tubercul- 
ous masses appeared immediately after incision of the 
skin. 

A fistula led to the left sinus, which was thoroughly 
curetted after complete removal of its anterior wall, 
and communication with the nose was established. 
Death took place twelve days after his admission. Post- 
mortem examination showed an abscess of the left 
mastoid process, extending to the cranial base, 
and the occipital foramen, into the interior of 
the cranial cavity, tuberculosis of the frontal 
sinus, but no perforation into the cranial cavity. ' ' 

In two of the other cases there was swelling of the 
frontal region and at operation cheesy masses were 
found within the sinuses with necrosis of the posterior 
walls. The third case, Vohsen's, had a fistula leading 
to carious bone within the sinus. 

Two cases of sphenoidal and ethmoidal suppuration 
of a tuberculous character, in one combined with a like 
process in the frontal and maxillary sinus, in the other 
with the maxillary alone, have been observed. The 
first and more extensive was described by Panse and 
concerned a young girl of 16 years. 

The sphenoidal and frontal sinuses were opened be- 
cause of a suspicion of involvement of one or the other, 
on account of a sudden blindness that developed one 
month after an operation for nasal polypi. Necrotic 
bone was found in each cell and giant cells were found 
in the scrapings. An ti syphilitic treatment availed 



296 



NASAL TUBERCULOSIS. 



nothing and since the girl's condition was constantly 
growing worse a radical operation was performed. 
There was some temporary improvement bnt death 
soon occurred, and post-mortem examination showed 
numerous disseminated foci of a tuberculous nature 
in the lungs, bronchial and cervical glands, and the 



#r V 







£t 



Fig. 71. 

left parietal bone. The optic nerve was destroyed and 
there was circumscribed meningitis. 

The second case was that of a prominent physician 
who died in Denver in the winter of 1906. He had ex- 
tensive disease of both lungs and several months be- 
fore death developed maxillary, sphenoidal and eth- 
moidal disease on the right side, following a tubercul- 



ACCE3S0EY SINUSES. 297 

ous infection of the right npper jaw. The correspond- 
ing lower jaw rapidly snccnmbed to the same process 
after a focns had become established in the region of 
the first molar. The condition of this alveolus is shown 
in Fig. 71 and Plate XX, Fig. 72. 

The clinical diagnosis and later course of the disease 
did not permit of any doubt as to the true conditions 
and the post-mortem gave conclusive evidence as to the 
cause of the suppuration. 

The pathological changes that take place in the 
sinuses do not vary greatly from those that occur in 
other structures, hence a separate description is not 
required. 

The prognosis is highly unfavorable; of the cases 
collected by Grleitsmann three only resulted in tem- 
porary cure and nothing is known as to the ultimate 
outcome. Eecurrences are to be anticipated. 

Coakley's case was well, both in regard to the local 
and general condition, one year after the arrest of the 
maxillary disease ; in the author's case the elapsed time 
is all too short to warrant any definite conclusions. 

DIAGNOSIS. 

Tuberculosis and syphilis of the nose present strik- 
ing similarities in their objective appearances and a 
differential diagnosis, without histologic examination 
or recourse to the therapeutic test, is often impossible. 

In the far advanced lesions we have the fact that 
tuberculosis usually involves the cartilaginous, and 
syphilis the bony framework, and that the former, in 
the majority of cases, is secondary to advanced dis- 
ease of the lungs and larynx. It must not be forgotten, 



298 NASAL TUBERCULOSIS. 

however, that both diseases may exist in the same indi- 
vidual, that a nasal tuberculosis may occur in one who 
has syphilis and that syphilis of the nose can occur in 
one suffering from general tuberculosis. 

The formation of large tumors, a common manifesta- 
tion of tuberculosis, is rare in syphilis. 

In the latter disease the subjective symptoms are 
usually much more severe; there is considerable sur- 
rounding inflammation, local and cephalic pain, ten- 
derness on pressure, &c. 

The typical variations and classical features of each 
are detailed on page 132. 

In other cases the lupus is accompanied by lacri- 
mation. lymphangitis of the lobule and destruction of 
the alae. 

Between lupus and tuberculosis a strict line cannot 
be drawn because they are practically identical, de- 
pending upon the same cause and differing only in 
minor clinical characteristics. 

Lupus is often associated with lupus of the skin or 
with a vestibular eczema, and then offers no difficulties 
in diagnosis. 

When primary within the nasal cavities, however, 
the differentiation may be exceedingly difficult; in gen- 
eral the tuberculous nodules are more sensitive al- 
though some cases of tuberculosis are unattended by 
pair or tenderness. The most significant feature of 
the tuberculous lesions is the absence of anytendency 
toward spontaneous arrest. In lupus we find nodules, 
ulcers and points of cicatrization side by side, in tuber- 
culosis nothing but progressive destruction. 



PLATE XX. 



Fig. 72. Extensive destruction of the mandible. 



PLATE XX. 



Fig. 72. Tuberculosis of the mandible. 




PLATE XX. 



DIAGNOSIS. 299 

The presence of profuse granulations, unaccompa- 
nied by ulceration, speaks strongly for their lupoid 
character whether or not there is skin involvement. 
Extensive infiltration is likewise in favor of lupus. 

Contrary to the commonly accepted assumption that 
the tuberculous cases occur most frequently in men, in 
contradistinction to lupus, I have been unable to find 
any striking dissimilarity in the two conditions. A 
large series of cases shows the following: 

Men Women 

Lupus 34.4% 65.6% 

Tuberculosis 30.5% 69.2% 

The age offers a better index : lupus occurs most fre- 
quently about the time of puberty and tuberculosis be- 
tween the ages of twenty and fifty. 

Caboche, who attempts to draw a sharp line be- 
tween the lupic and tuberculous lesions, gives the fol- 
lowing points upon which the differential diagnosis is 
to be based: 

' ' 1. We can surely list as pituitary lupus the cases 
of tuberculosis where there is remarked one or sev- 
eral of the following signs :" 

"Mammillated infiltration of the mucosa, which I 
regard as the typical lesion of lupus." 

"Perforation of the septal cartilage." 

"Destruction of the alae nasi." 

"Coexistence of other lupic lesions of the nose, cheek 
and face in general." 

"Coexistence of other lupic lesions of the mucosa." 

"Narinal atresia in tunnel form." 

"2. "We can almost, with certainty, include as lupus 
the cases where one of the following signs is shown:" 

' ' Long duration of the affection. ' ' 



i i 

C i 



300 NASAL TUBERCULOSIS. 

"Frequent recrudescences in spite of methodical 
treatment. ' ' 

Lymphangitis of the lobule." 

The presence of vermicular cicatrices of the lobule 
or at the narinal orifices." 

"The presence of ' eczema ' of the nares, which, in 
several cases, seems to me to have been nothing else 
than vestibular lupus. ' ' 

"These signs acquire the value of certainty if they 
coexist with one of the symptoms above mentioned. ' ' 

' ' The absolute indolence of lupus contrasts with the 
pain, often sharp, of miliary tubercular ulcerations." 

■ ' I may add that the rarity or absence of bacilli upon 
histologic examination is also in favor of lupus." 

Aside from syphilis and lupus, the only conditions 
capable of causing confusion are the new growths, 
either benign or malignant. 

Certain cases of tuberculomata have some resem- 
blance to simple mucous polypi, but the latter are gen- 
erally multiple, have their attachment usually in the 
middle meatus or ethmoidal region and are more 
pedunculated, movable, compressible and transparent 
than the tuberculous growths. 

The diagnostic features of the malignant growths are 
fully considered in the chapter on Diagnosis, Part I, 
and need not be here reiterated. 

As a final diagnostic recourse we have the histologic 
demonstration of tuberculous tissue and the discovery 
of the bacillus in the secretions and scrapings.. 

As is the case with the larynx, anti- syphilitic treat- 
ment may cause temporary improvement of the tuber- 
culous lesions, but this betterment is fleeting and at the 



DIAGNOSIS. 301 

end of two or three weeks all evidences of the improve- 
ment have usually disappeared. 

PKOGNOSIS. 

Nasal tuberclosis, in itself and uncomplicated, is the 
least fatal form of phthisis and runs an exceedingly 
sluggish course. It occasions but little depression and 
malnutrition, and hence, unless it extends to the men- 
inges or provokes constitutional tuberculosis, may en- 
dure for many years. 

In some instances the disease has spread to the eye 
by way of the lachrimal duct, the cervical glands are 
often infected, and when the posterior part of the nose 
is diseased the process may extend to the naso- 
pharynx. 

The lymphatic glands become involved in a consider- 
able number of cases, at least twenty-five per cent show- 
ing some enlargement. The cervical, submaxillary, 
sublingual and preauricular glands have all been in- 
volved, sometimes on one side only and occasionally 
on both sides. 

Involvements of the tear-ducts have been especially 
considered by Caboche (Ann. des Mai. de VOreille, du 
Lar., du Nez et du Phar., Sept., 1906). 

He claims there is a form of vegetating nasal tuber- 
culosis having its origin in the inferior meatus which 
rapidly invades the tear-ducts, constituting a naso- 
lacrimal tuberculosis. It occurred in thirteen of 
twenty-four cases of nasal lupus. 

The symptoms are nasal obstruction and epiphora. 
The objective symptoms consist of hypertrophy of the 
inferior turbinated body concealing fungous lesions of 



302 NASAL TUBEKCTJL0SIS. 

the meatus, lachrimal fistula aud cutaneous tubercu- 
losis as an early sequel. In five out of nine cases re- 
ported by Kingsberg the disease extended from the 
nose to the lachrimal duct and eye. 

Each new focus means a corresponding decrease in 
the chances of eventual arrest. 

Even in the apparently primary cases, relapses 
after the lesions are seemingly arrested or cured are 
very common. 

With the secondary lesions the prognosis depends 
almost entirely upon the extent of involvement in the 
other organs, the general nutrition, &c. It is as a rule 
a late complicatiou and therefore increases greatly 
the gravity of the general prognosis. The local lesions 
themselves seldom cicatrize unless seen and vigorously 
treated during the stage of sharp circumscription. 

The lupic cases are generally amenable to treatment 
although they pursue a very protracted course. 

TREATMENT. 

The treatment of nasal tuberculosis should follow the 
general lines laid down for the larynx. Where pos- 
sible, the disease should be treated as a local tubercu- 
losis and be thoroughly eradicated. Surgical treat- 
ment is always advisable provided the disease is local 
and has resisted simple treatment; if it is a secondary 
localization and the general prognosis is unfavorable, 
no attempt at removal should be made unless the lesion 
is both accessible and sharply circumscribed. If the 
disease is not extensive it exerts but little influence 
upon the constitutional condition, and an extensive 



PKOGNOSIS TKEATMENT. 303 

operation, even if it gave promise of completely curing 
the nose, would have a deletrious effect in general. 

A. Onodi (Deutsche med. Wochenschr., July 19, 1906) 
recommends for primary disease of the septum, of 
large extent, that the nasal cavity be opened in the 
median line with osteoplastic resection of the nasal 
bone and the frontal process of the superior maxillary, 
followed by complete resection of the involved portions 
of the septum. 

As the process is practically painless we are sel- 
dom confronted with the alternative that so frequently 
presents in the larynx, and hence but two lines of treat- 
ment are to be considered : complete removal when the 
disease is circumscribed and the general disease amen- 
able to treatment, and symptomatic management when 
the organic tuberculosis is advanced and the nasal 
lesion widespread. In the former case a complete cure 
may frequently be attained. 



CHAPTER XVI. 
THE NASOPHARYNX. 

History. 

The general recognition and study of tuberculous le- 
sions of the nasopharynx is largely a development of 
the past decade, yet nearly thirty-five years have 
passed since the first authentic observations were rec- 
orded. 

The pioneer work was done by Wendt, who in 1874 
(Krankheiten d. Nasenrachenliohle u. d. Racliens. 
Ziemss, Handbuch, Bd. VII, I.) brought the subject 
into prominence by his statement that tuberculous ul- 
cers appear occasionally within the post-nasal space 
and that their point of election is the third tonsil, al- 
though the region about the orifices of the eustachian 
tubes is also occasionally invaded. 

Little of additional value was adduced until six years 
later, when Barth and Zawerthal, in independent the- 
ses, drew attention anew to the subject. 

The former (De la Tubercalose du Pharynx et de 
Vangine tubercl.) described three cases, in one of 
which, a lesion secondary to extensive ulceration of 
the posterior and lateral walls of the pharynx, there 
was deep ulceration and total destruction of the eu- 
stachian orifices. 



HISTORY. 305 

Zawerthal (Wien. Med. Presse, 41-43, 1880) first ad- 
vanced the fact of the occasional primary localization 
of the tnbercnlons process in the nasopharynx. 

In the following year, 1881, E. Frankel (Anat. u. 
Klin. z. Lehre v. d. Erkrank. d. Nasenrachenraumes u. 
Gehororganes b. Lung ens chwinds., Zeitschr. f. Ohren- 
heilk., X, 2 Heft) published the results of fifty autop- 
sies upon persons dead of consumption. In ten of these 
cases there was tuberculous ulceration of the post- 
nasal space, generally of the tissues contiguous to the 
tubal apertures. 

Not one case of acute miliary tuberculosis was in- 
cluded in this series. 

Frankel maintained that under certain conditions 
these ulcers might remain latent and be discovered 
only through anatomical examination, and that while 
they usually develop in patients with advanced pul- 
monary or other organic tuberculous disease, they oc- 
cur rarely in individuals having but slight involvement. 
An extension of the process to the ear had not oc- 
curred in a single one of these patients. 

Additional cases were now reported in quick suc- 
cession, by Hinkel, Suchannek, Michelson, Northrup, 
and others. 

In Hinkel 's patient (Report of a case of Tubercular 
Ulceration of the Pharynx, Western New York Med. 
Press, May, 1886) there was ulceration of the nasal 
surface of the soft palate in association with extensive 
tuberculous disease of the larynx, tonsils and pharynx. 

Suchannek (Beitr. z. norm. u. path. Anat. d. Rachen- 
gewolbes, Ziegler's Beitr. z. Path, Anat., Bd. Ill, 
1888) supported Frankel 's statement that ulcers of 



306 NASOPHARYNGEAL TUBERCULOSIS. 

the vault might remain a long time latent, and like- 
wise advanced the fact that some apparently simple 
erosions show tnbercle bacilli upon microscopical ex- 
amination. 

In 1889, M. Hajek of Vienna (D. Tuberc. d. Nasen- 
sckleiwihaut, Klin. Rundschau., S. 118) brought for- 
ward the first case of a tuberculous tumor in this lo- 
cality. The growth was situated upon the upper sur- 
face of the soft palate and there was also tuberculous 
ulceration of the nose, involving the cartilaginous sep- 
tum. In this case the lesion was undoubtedly second- 
ary to pulmonary consumption, there having been a 
history of a previous hemorrhage. 

Two years later Schnitzler (Beitr. z. Kenntn. d. Tu- 
ber cidinivirhung, Wein Klin. Wocliensclir., 12, 1891) 
placed on record a very unusual case of tumor forma- 
tion resulting from the injection of tuberculin. This 
patient, a man 31 years of age, had tuberculosis of the 
lungs and larynx but the nasopharynx was apparently 
unaffected, and yet, some days after the use of the 
tuberculin, miliary tubercles appeared. The involve- 
ment of the nasopharynx followed a miliary outbreak 
in the pharynx and this had been preceded for some 
days by a similar eruption upon the epiglottis. At the 
pharyngeal vault the nodules rapidly enlarged and 
coalesced until a tumor of large size resulted. The 
continued use of tuberculin, however, caused the 
growth to break down and ulcerate, with eventual heal- 
ing. 

In regard to the frequency with which tuberculous 
lesions of this region occur, the most valuable contri- 
butions were made by Dinochowski (Ueb. sec. Affect 



HISTORY. 307 

d. Nasenrachenhohle b. Phthisikem., Ziegier's Beitr. 
z. Path. Anat., Bd. XVI., 1894). He examined 64 con- 
sumptives, including eight cases of acnte miliary tu- 
berculosis, and found 21 with tuberculous invasion of 
the nasopharynx and in consequence of these findings 
reached the conclusion that secondary affections of the 
post-nasal tissues are very common, and that they are 
especially frequent in cases of acute miliary tubercu- 
losis. 

Habermann (cited by Thost. Monatsschr. f. Ohren- 
heilk., 1896) met with two cases of ulceration in eight 
cases which he examined, but the great majority of the 
authorities, however, looked upon this case as a most 
uncommon manifestation of the disease. 

Cases of tumors, in addition to those of Hajek and 
Schnitzler already cited, were recorded by Touton (IV 
Congr. d. Deutschen Derwiat. Ges., 1894) ; Koschier 
(Ueb. Nasentuberculose. Wiener Klin. Wochenschr, 
36-42, 1895); Avellis (Cited by M. Schmidt) and 
others. 

One of the earliest communications respecting the 
localization of the disease in the pharyngeal tonsil was 
made by Trautmann (Anat. Pathol, u. Klin. Studien 
ueb. Hyperplasie d. Rachentonsille, Berlin) in 18S6. 
He declared that tuberculosis was nearly always the 
cause of adenoid growths, and in a later work 
(Schivartze's Handbuch d. Ohrenheilk., Bd. II, S. 135, 
1893) he maintained his former position, although ad- 
mitting the general impossibility of demonstrating 
either giant cells or bacilli in the glandular tissues. 

He based his conclusions on the well established fact 
that a large proportion of the children of consumptive 



308 NASOPHARYNGEAL TUBERCULOSIS. 

parents have adenoid vegetations, and also upon the 
positive results of the tuberculin test in many in- 
stances. 

In a large majority of the cases of pharyngeal ton- 
sil hyperplasia, the injection of tuberculin produced 
some pyrexia with an increase in the local tumefac- 
tion. The continued use of the tuberculin, however, 
led usually to the gradual retrogression of these symp- 
toms, with eventual disappearance of the adenoids. 

While few succeeding authors adopted the advanced 
stand taken by Trautmann, still the steadily increas- 
ing number of cases in which the tonsillar localization 
was proven, either with or without visible increase in 
size, directed attention to its possibility and caused 
painstaking examinations to be made in a large number 
of cases. 

Few of the early examinations, however, revealed 
either giant cells or bacilli. Cornil (Tube ratios e larvee 
des trois amy g dales, Ac. de med. de Paris, 1895) made 
examinations of 70 hypertrophied tonsils without find- 
ing bacilli in a single case and giant cells only four 
times. Of ten specimens examined by Pilliet (Soc. 
Anatom., March 25, 1892), three contained giant cells 
but bacilli were totally lacking. 

The majority of the investigators, including Seifert, 
Kahn, Chatelier, Luc, and Dubief, were unable to find 
any evidences of tubercle formation in extirpated ton- 
sils, but it is perhaps possible that the negative results 
depended upon the fact that the sections did. not pass 
through the affected areas and that only a few sec- 
lions were made, for it is now a well known fact that 
the process is always localized in certain areas and is 



HISTOKY. 309 

never diffused throughout the entire gland. A localized 
involvement may, therefore, be easily overlooked. 

On the other hand, a number of positive results were 
soon recorded. Both bacilli and giant cells were found 
in the adenoid tissue by Lermoyez ; in 32 cases, offer- 
ing no macroscopic evidences of phthisis, he found tu- 
bercles in two. In several additional cases pulmonary 
tuberculosis developed upon the removal of the 
growths. 

So many cases of this kind, i. e., instances of dissemi- 
nated tuberculous infections following the removal of 
hyperplastic pharyngeal tonsils, have now been as- 
sembled, in addition to those in which microscopic evi- 
dences of the disease have been found, that a doubt can 
no longer exist that the condition is comparatively 
frequent and that this lymphatic tissue is a not uncom- 
mon portal through which the bacilli gain entrance into 
the body. 

ETIOLOGY. 

Post-nasal tuberculosis is usually secondary to far 
advanced disease of other organs but apparently pri- 
mary cases, particularly of the tonsil, have been rec- 
orded in a considerable number of instances. 

As to the frequency of tuberculous involvements of 
the nasopharynx it is almost impossible to quote 
figures of definite worth, because of the fact that in 
the majority of instances there are no macroscopical 
alterations, and deductions must therefore be drawn 
almost entirely from microscopical examination of ex- 
cised tonsils and animal inoculations. 

From the following tables a fairly clear idea may be 
had, however, of the frequency of the various types : 



310 NASOPHAKYNGEAL TUBERCULOSIS. 

A. 

Secondary Ulcerations of the Nasopharynx. 

Author Consumptives Ulceration 

Frankel 50 cadavers 10 

Habermann 8 8 

Dmochowski 64 21 

Author 904 consumptives 15 

Total 1026 48 

B. 

Primary Tonsillar Tuberculosis. 
Histological Diagnosis. 

Author Adenoids Examined Tuberculosis 

Wright 51 

Piffl 100 1 

Cornil 70 4 

Pilliet 10 3 

Lermoyez 33 3 

Broca 100 

Brindel 64 8 

Pluder & Fischer 32 5 

Gottstein 33 4 

Author 51 3 

Total 544 31 

Of these cases the diagnosis in seven (those of Cor- 
nil and Pilliet) was based upon the presence of giant 
cells alone, no bacilli having been found. 

A number of other cases have been uncovered by 
means of inoculation tests upon guinea pigs. 

a 

Inoculation 
Author. Tests. Tuberculosis. 

Lewin 100 10 

Baup 45 1 

Dieulafog 35 7 

Lartigan & Nicoll 75 12 

Wright 12- 

Total 267 30 

In a total of 1837 rases there were L15 oi' nasopha- 
ryngeal tuberculosis, or 6.2 per cent. 



ETIOLOGY. 311 

Of these cases 1026 were consumptives, and of them 
54, or 5.2 per cent, had ulcerative lesions that were 
macroscopically recognizable. 

The remaining 811 cases, individuals apparently free 
from tuberculosis, from whom the adenoid tissue was 
removed and examined, showed tuberculosis in 61, or 
7.5 per cent. 

When there is advanced disease of the lungs, how- 
ever, and particularly when complicated by laryngeal 
involvement, the percentage of tonsillar involvements 
is greatly increased ; thus in 136 such cases the tonsils 
were tuberculous in 94, or 68 per cent. 

The large majority of the ulcerative lesions are 
secondary in nature but a few of apparently primary 
origin have been noted, especially by Dmochowski, who 
in three cases believed the tonsillar lesion to have been 
the cause of acute miliary tuberculosis. 

Hurd (Laryngoscope, July, 1907) reported an inter- 
esting case of an apparently primary tuberculous 
growth of the nasopharynx that occupied the vault 
and posterior wall. The growth was slightly nodular 
and covered by a normal appearing mucous membrane. 

The report of the pathologist, Dr. Jonathan "Wright, 
was as follows: "Microscopic examination of a piece 
removed by forceps shows that in mounting the hard- 
ened specimen crumbled from the hardening process. 
Many of the fragments show very plainly perfectly 
typical tubercle. Centres of tubercle granulum or ne- 
crobiosis are surrounded by a rim of new connective 
tissue in attempts at repair. In a few of these areas 
may be seen a typical Langerhans giant cell. Some of 
the round cell tissue apparently at a distance from the 



312 NASOPHAKYNGEAL TUBERCULOSIS. 

tubercles is altered somewhat by chronic inflammation 
and contains no lymph nodes. The tubercular tissue, 
or rather the tubercle granula, are not immediately un- 
der the epithelium which is fairly normal columnar, 
but separated from it by a rim of lymph cells. This is 
the second case only which I have seen in which there 
were multiple tubercles in a posterior lymphoid hyper- 
trophy, the other having been from the service of Dr. 
Chappell and reported by me with a color plate in the 
New York Medical Journal, Sept. 26, 1896. Perhaps, 
owing to the scantiness of the lymphoid tissue, there 
being no nodes, it is not accurate to call this tubercle 
of the adenoid, but of the nasopharynx." 

"A search of 10 sections failed to reveal any tubercle 
bacilli. ' ' 

" March 15, 1906. Two guinea pigs inoculated." 
"June 6th, 1906. One of the guinea pigs inoculated 
two months before with pieces of the growth removed 
from the naso-pharynx beneath the skin of abdomen 
showed enlarged inguinal glands. The other guinea 
pig showed beginning round celled infiltration (pre- 
sumably tuberculosis) of the smaller bronchi." 

SOURCE OF INFECTION. 

The chief factor in etiology consists in the peculiar 
anatomical conformation of the parts. We have to 
deal with a sort of sac or pouch, blind upon its superior 
and posterior aspects, but communicating from its an- 
terior surface with the nose, and inferiorly with the 
pharynx and mouth and through these latter channels 
with t he larynx and lungs. 

The space is therefore open to infection from two 
sides : from the nose by inhalation or extension by con- 



ETIOLOGY. 313 

tiguity, and from the lower segments of the respiratory 
tract by direct transference of bacilli in sputum and 
vomitus, as well as by direct spread. The conforma- 
tion of the remaining parts, the blind surface of the 
pouch, favors the indefinite retention and growth of 
all germs so deposited. 

At the upper end of the sac, the point where the in- 
spired air current strikes with greatest force and there- 
fore where the largest deposit of germs occurs, the mu- 
cosa is thrown into a number of uneven folds and fur- 
rows by a considerable collection of lymphatic tissue, 
the so-called Luschka's, or third tonsil. Even in its nor- 
mal state this gland offers a favorable culture field by 
reason of its uneven surface and deep crypts, within 
which the epithelial lining is often desquamated. This 
nidus is rendered still more fertile, however, by reason 
of the fact that it is both inflamed and enlarged in the 
great majority of all consumptives. In children under 
the age of puberty some enlargement of the tonsil, and 
therefore an increase in the depth of the crypts, is al- 
most always present, and in many cases it is of a de- 
gree sufficient to give rise to the condition recognized 
as adenoids. 

Both of these conditions, glandular hypertrophy and 
simple inflammation or catarrh, strongly favor infec- 
tion, because the consequent narrowing of the respira- 
tory channel causes the air to impinge with unnatural 
force against the damaged tissue, the crypts form a 
barrier to the expulsion of the bacilli thus deposited, 
and their penetration into the deeper structures is 
facilitated by the numerous erosions existent and by 
the frequent replacement of the normal ciliated epithe- 



314 NASOPHARYNGEAL TUBERCULOSIS. 

Hum by one of a squamous type. As has been shown 
to be the case with the larynx, some antecedent weak- 
ening of the tissues is almost invariably necessary to 
the development of the tubercle bacilli ; in other words, 
a point of locus minoris resistentia must have been 
created and this favorable soil is produced by both of 
these above considered conditions. 

That inhalation infection does not occur with even 
greater frequency is due to the arrest of the majority 
of all foreign bodies in the anterior chambers of the 
nose. The effectiveness of the nasal passages as a filter 
has been proven by various experiments, only a few of 
which need be here cited : 

Of 29 apparently normal men examined by Strauss, 
9 had tubercle bacilli in the nasal secretions. 

Hildebrandt (Exper. Unters. uber d. Eindringen 
pathogener Mikro organism en v. d. Luftivegen, u. d. 
Lunge aus. Ziegler's Beitr. z. path. Anat., Bd. II, 1888) 
subjected rabbits to the nasal inhalation of Aspergillus 
Fumigatus without the production of any pulmonary 
changes, but when the inhalations were given through 
a tracheal cannula the characteristic hepatization read- 
ily occurred. 

In The Medical Record of August 25, 1900, W. 
Noble Jones reported the results of his experiments in 
injecting guinea pigs with the nasal secretions of aver- 
age healthy persons not unduly associated with con- 
sumptives, in which he had a positive result in 10.3 
per cent of the cases. (See Page 2(i()). 

Those organisms that succeed in passing through the 
Dose are deposited, as a rule, in Hie region between the 
roof of the nose and the posterior wall, the area oc- 



ETIOLOGY. 315 

cupied by Luschka's gland and where the conditions 
are most favorable for their development. 

There are several additional factors, however, which 
under normal conditions militate strongly against in- 
fection. In the first place the epithelium is of the 
ciliated variety and tends to expel all foreign bodies 
there deposited; secondly, there is a film of tenacious 
mucus such as exists in the nose that prevents their 
deposit or long retention, and thirdly, the tubercle 
bacillus requires a considerable period of time in which 
to develop and produce pathologic changes in the tis- 
sues. 

Under two conditions, however, these defenses, may 
prove inadequate : First, when points of locus minoris 
resistentiae exist, and second, when large numbers of 
tubercle bacilli are simultaneously introduced. 

We have seen that adenoid vegetations act as a 
strong predisposing moment and retro-nasal catarrh 
is almost equally potent. This has been clearly shown 
by Freudenthal (Kleiner e Beitr. z. Aet. d. Lungentu- 
berculose, Arch. f. Laryng., Bd. V, 1896) in his exami- 
nations of the post-nasal secretions of 133 patients of 
the Montefiore Home who had no symptoms referable 
to the nose or throat. 

Of these patients 52 were tuberculous and 81 non- 
tuberculous. Of the 52 with consumption, 21 had naso- 
pharyngeal catarrh, and of the 81 non-tubercluous, 34. 

Tubercle bacilli were found in the secretions of 24 
of the cases of tuberculosis and in nine of those not 
suffering from the disease. Certain of the non-tuber- 
culous cases that had bacilli in the secretions developed 
tuberculosis later, strong presumptive evidence that 



316 NASOPHARYNGEAL TUBERCULOSIS. 

the disease had its primary localization in the naso- 
pharynx. 

Atrophic rhinitis mnst be looked npon as an import- 
ant predisposing factor in some cases. In this disease 
the physiologic functions of the nose, as a filterer and 
moistener of the inspired air, are almost entirely de- 
stroyed, for in place of the normal convolntions the 
passages are wide and straight and the mncosa is 
more or less completely deprived of its normal secre- 
tions and cilia. 

As a result, the majority of the foreign bodies that 
are drawn into the nose, instead of being arrested near 
the introitus pass through and are deposited in the 
nasopharynx, and as there is always an accompanying 
nasopharyngitis in this condition, the bacilli find a 
favorable field for development. 

While inhalation undoubtedly plays the most import- 
ant role in the etiology of post-nasal tuberculosis, the 
disease in some instances is due to lymphatic and blood 
transmission, in others to infection from the lower seg- 
ments of the respiratory tract. In the act of coughing, 
particles of infected sputum may be thrown into the 
nasopharynx and vomiting sometimes results in con- 
siderable quantities of food being forced up behind the 
palate, while in the majority of cases of laryngeal tu- 
berculosis accompanied by dysphagia and odynopha- 
gia, some regurgitation of food, both liquid and solid, 
accompanies almost every effort at deglutition. 

The imperfect apposition of the palate to the poste- 
rior wall, through which this entrance of food and 
sputum into the post-nasal space is made possible, is 
due to one of two causes: in coughing incomplete clos- 



PLATE XXL 



Fig. 73. Tuberculosis of the pharyngeal tonsil, with sinus 
leading to necrotic bone. 



PLATE XXL 



Fig. 73. Tuberculosis of the pharyngeal tonsil. 




Fig. 73. 



PLATE XXI 



ETIOLOGY. 317 

ure may result from attempts at suppression through 
keeping the mouth tightly closed, a common practice 
with consumptives when in the presence of strangers or 
at the table; an additional cause is undoubtedly to be 
found in that tumefaction of the parts which is a not 
uncommon accompaniment of laryngeal tuberculosis. 

These factors explain why infections in the region of 
the pharyngeal tonsil occur chiefly during the late 
stages of phthisis pulmonalis. 

An active but rather rare cause in advanced cases is 
direct extension of the process from neighboring foci, 
i. e., in the nose, sinuses, pharynx, buccal cavity, &c. 

Just what role the primary infections of the naso- 
pharyngeal lymphatic tissue play in the development 
of tuberculosis of other organs cannot be definitely de- 
termined, but it can no longer be doubted that they 
are of great etiologic moment. 

In a not inconsiderable number of primary pharyn- 
geal tonsil infections an acute miliary tuberculosis of 
the lungs has been super-added, and the majority of 
cases of cervical lymphadenitis may be traced to dis- 
ease of the pharyngeal and faucial tonsils. Both pul- 
monary and laryngeal foci have oftimes resulted, ac- 
cording to many authorities, from preceding disease 
of the cervical glands. 

On the other hand, the process may remain latent 
for a long time or even be permanently arrested and 
leave no trace of its previous existence. 

The question is not entirely academic for it has a 
strong bearing upon the problem of operative interven- 
tion ; whether the infective focus should be radically ex- 
tirpated to prevent further dissemination, or whether, 



•> 



18 NASOPHAKYNGEAL TUBERCULOSIS. 



on the other hand, such procedures favor extension to 
new organs or ulceration at the point of excision. 

This point has not been definitely settled but it ap- 
pears reasonable to conclude that excision, as with tu- 
berculous processes of other organs that are purely 
local, will afford the best chance of permanent arrest. 

When such enlargements exist, aside from their 
baneful effects upon the general nutrition which would 
favor the development of tuberculosis in those other- 
wise predisposed, there is constant danger of acute in- 
flammatory processes supervening, which are even 
more liable to cause dissemination than the traumat- 
ism arising from a clean and rapidly healing wound. 

That delayed healing may occasionally result in these 
cases, however, has been shown by Hessler (Ueb. d. 
per at. d. aden. Vegetal, m. d. neuen Schutz'schen 
Pharyngotonsillstom., Munch, wed. Wo aliens chr., 29, 
1895). He operated one child and resolution was nor- 
mal, but in her sister healing was greatly delayed; 
there was great swelling of the cervical glands, profuse 
secretions, fever and general prostration that lasted 
for weeks. It only subsided when the child was re- 
moved to a more favorable climate. There was tuber- 
culosis in the family and several had died of it, and this 
child, in physical characteristics, resembled these mem- 
bers. 

Extension may likewise occur even when the gland 
has not been subject to traumatism, hence the existence 
of such an area is a constant menace for not alone are 
there possibilities of pulmonary and glandular infec- 
tion-. Inil of aural involvements and of extension to the 
retropharyngeal glands and meninges as well. 



OBJECTIVE SYMPTOMS. 319 

OBJECTIVE SYMPTOMS. 

Three forms of nasopharyngeal tuberculosis are 
clinically recognizable : 

1. Involvement of the adenoid tissue. 

2. Ulceration. 

3. Tumors. 

1. The Pharyngeal Tonsil. The frequency and etio- 
logic factors concerning tuberculosis of the lymphatic 
glands of the vault have already been considered, so 
there remain for discussion only the clinical and diag- 
nostic features. 

Considerable enlargement, when occurring in indi- 
viduals with well marked involvement of the lungs or 
other organs, may safely be looked upon as tubercu- 
lous for the vast majority of such cases have been 
proven to be so, but in the absence of other signs of 
the disease, histologic examination of the excised tis- 
sue or animal inoculations can alone determine wheth- 
er the hyperplasia is due to simple inflammatory 
changes or to a latent tuberculous focus. 

There may be widespread tuberculous involvement 
without macroscopic alterations and this is indeed the 
usual condition, as has been shown in considering the 
etiology of the laryngeal lesions. 

Seifert (Heymann's Handbuch der Laryngologie und 
Rhinologie, p. 719), in determining the probability of 
an hypertrophy being due to tuberculosis, directs at- 
tention to the following points : 

(1). History, heredity, &c. 

(2). Existence of other scrofulo-tuberculous signs 
in the skin or glands. 



o 



20 NASOPHAKYNGEAL TUBEKCULOSIS. 



(3). Severe disturbances of nutrition not in har- 
mony with the usual picture of adenoids. 

Several investigators claim that tuberculosis is the 
almost invariable cause of glandular overgrowth, but 
this advanced hypothesis is not substantiated by pa- 
thologic study, which shows only an approximate five 
per cent in which indisputable evidences of tubercu- 
losis have been found. 

On the other hand it cannot be gainsaid that the hy- 
pertrophies occur most frequently in the children of 
tuberculous parents or of families some members of 
which have the disease, and there is usually simultane- 
ous enlargement of other lymphatic tissues, i. e., the 
faucial tonsils, lingual and cervical glands. 

Aside from the hyperplasia there are no symptoms 
evoked, either local or constitutional, through which a 
differential diagnosis is made possible. 

It is well to reiterate at this point that latent tubercu- 
losis of this tissue may exist without any increase in 
size, and even in glands that have become atrophic. 

Whether the hypertrophy usually depends upon the 
bacillary infection or whether there is generally a 
preceding enlargement upon which the tuberculous pro- 
cess is grafted, is disputed, but we can state quite pos- 
itively that both theories are tenable. It has been shown 
that the disease is sometimes found in normal sized 
tonsils and even in those which have undergone atro- 
phy, and certain histological and clinical considera- 
tions point to the assumption that the hypertrophy usu- 
ally precedes the bacillary infection. 

The tuberculosis is limited to the lymphoid tissue and 
does not involve the submucosa, and the bacilli are met 



PLATE XXII. 



Fig. 74. Ulceration of the nasal surface of the soft palate 
and uvula, secondary to advanced disease of the 
pharynx. 



PLATE XXII. 



Fig. 74. Ulceration of the nasal surface of the soft palate 
and uvula.. 



iC'i 




\ 





Fig. 74. 



PLATE XXII, 



CALMETTE EEACTION. 321 

with only in the affected areas and never in the healthy 
lymph follicles or npon the epithelium. 

The process is not a diffuse one but is circumscribed 
to certain segments ; it may involve an entire lobe of the 
gland or only certain portions of it, while the neigh- 
boring lobes remain entirely normal. 

If the hyperplasia invariably depended upon bacil- 
lary infection, it would be rational to conclude that oc- 
casionally the disease would be found more or less dif- 
fused throughout the entire gland, in place of the con- 
stant limitation to circumscribed segments and tissues. 

Certain clinical phenomena uphold this idea, i. e., 
the infection of an already existing hyperplasia; re- 
currences after extirpation are exceedingly uncommon, 
transmission to other organs is rare and the process 
is usually completely checked. 

That the hyperplasia does in certain instances de- 
pend entirely upon the tuberculous infection cannot be 
gain- said any more than the contrary view, but all con- 
siderations point to the probability that there is in the 
majority of cases a primary enlargement. 

In determining whether or not a latent lesion is pres- 
ent in the nasopharynx, the opthalmo-reaction of Cal- 
mette may prove of some service. The injection into 
the eye of a solution of dry tuberculin, precipitated by 
alcohol at 95 degrees, in distilled and sterilized water, 
usually produces a congestion of the tarsal conjunc- 
tiva within three to five hours, although it may be de- 
layed 24 or even 48 hours, provided the body conceals 
a tuberculous lesion. The membrane becomes a bright 
red in color and there is more or less edema and mod- 
erate lachrimation. 



322 NASOPHARYNGEAL TUBERCULOSIS. 

Pain does not occur and results do not usually follow 
unless there is tuberculosis. The reaction reaches its 
maximum in from six to seven hours and dies away in 
from one to one and a half days. In children 
no signs are left after about 18 hours. As 
most of the cases of latent disease of the tonsils 
occur in those without other tuberculous foci, the test 
may be of great service in determining the nature of 
these lymphoid enlargements. The reaction does not 
occur in very young babies. Recent experiments, how- 
ever, show that the reaction does not invariably occur 
even in the presence of undoubted tuberculosis, especi- 
ally in incipient and very old and advanced cases, and 
that it sometimes occurs in conditions not allied with 
tuberculosis, i. e., certain senile and gonorrheal bone 
diseases. 

In one case, reported by Seraflni {Gior. d. R. Accad. 
di. Med., Turin, Nov., 1907), there resulted an in- 
creased activity in the lungs and glands, with general 
phenomena. 

Lewin (Archiv. fur Rhinol. u. Laryngol., Berlin, B. 
9, H. 3) bases the following conclusions upon the re- 
sults of an examination of 200 subjects: 

"(1). According to our investigations, hyperplas- 
tic pharyngeal tonsils conceal tuberculous lesions in 
about 5 per cent of the cases. 

"(2). The tuberculosis is present in the so-called 
tumor form, it is characterized by the absence of sur- 
face indications of its presence — latent tuberculosis of 
the tonsils. 

"(3). This * latent' tuberculosis may apparently be 



OBJECTIVE SYMPTOMS. 32 



o 



the first and indeed the only localization of the disease 
in the individual. 

"(4). It is generally, however, associated with 
other tuberculous processes, generally of the lungs, 
which may, however, not have developed at the time the 
tonsil was operated upon. 

"(5). It is a comparatively frequent condition 
among those suffering from tuberculosis of the lungs. 

" (6). It is found in the normal sized tonsil as well 
as in the hyperplastic. Whether it may cause hyper- 
plasia by the development of some toxin is doubtful. 
It can, however, retard the normal involution of the 
tonsil. 

" (7). Its part in the etiology of hypertrophy of the 
pharyngeal tonsil is unimportant. 

" (8). By removal of the tonsil the disease may be 
removed, even though tuberculosis of the lungs be 
present." 

2. The Ulcer. Tuberculous ulceration in the naso- 
pharynx may occur either as a primary or secondary 
manifestation of the disease, but the latter represents 
the by far more common type although a considerable 
number of apparently primary cases are recorded. 

The condition is seldom recognized clinically owing 
to the fact that systematic examinations are rarely 
made in advanced cases of phthisis unless severe sub- 
jective throat symptoms are evoked, but in post-mor- 
tems upon people dead of consumption it is found in a 
not inconsiderable percentage of the cases. 

This discrepancy has already been shown; ulcers 
were found in ten of 50 consumptives examined post- 
mortem (20 per cent), while in 904 living cases of local 



324 NASOPHAEYNGEAL TUBERCULOSIS. 

tuberculosis they were seeu but fifteen times or in 
about one and one-half per cent of the cases. 

In a number of additional cases there were super- 
ficial erosions that appeared to be of a simple catarrhal 
nature, which disappeared under treatment, and it 
may have been the presence of such lesions as these, as 
well as of adherent purulent masses about the edges 
and within the crypts of the bursa, that led many ob- 
servers to a mistaken diagnosis and the consequent 
impression that tuberculous ulceration is a compara- 
tively common affection. 

The true ulcer, however, is without doubt extremely 
rare even in advanced cases of general tuberculosis. 
It is found most frequently in cases of acute miliary 
tuberculosis. 

Seifert says he has rarely seen the condition, 
despite painstaking rhinoscopic and post-rhinoscopic 
examination of every consumptive, and Schmidt has 
had the same experience. 

The ulcer in this space has the same characteristics 
as tuberculous ulcers of other mucous membranes and 
demands no separate description. Its chief point of 
difference consists in its tendency to spread towards 
the depths and involve the deeper structures more rap- 
id I y and constantly than does its laryngeal prototype. 
(Plate XXI, Fig. 73.) 

The lymphatic tissue usually melts away with sur- 
prising rapidity, as is seen in cases where. the faucial 
tonsils are secondarily involved. The base is nearly 
always uneven and covered by profuse granulations 
and tenacious muco purulent secretions, and the pa- 



PLATE XXIII. 



Fig. 75. Tuberculosis limited to the posterior lip of the 
Eustachian tube and Rosenmueller's fossa. 



PLATE XXIII. 



Fig. 75. Tuberculosis limited to the posterior lip of the 
Eustachian tube and Rosenmuller's fossa. 







f^Nx^i— l— y- p<gl 



Fig. 75. 



PLATE XXIII. 



TBEATMENT. 325 

thognomonic miliary tubercles are usually to be seen 
about the ulcers and in the adjacent membranes. 

The process is occasionally localized upon the upper 
surface of the soft palate, and I have seen one case in 
which the ulcers were limited to Bosenmuller's fossa 
and the posterior lip of the tube. (Figs. 74 and 75, 
Plates 22 and 23.) 

The prognosis is generally unfavorable, in that the 
lesion nearly always occurs late in the course of pul- 
monary and laryngeal tuberculosis; in such instances 
symptomatic treatment is alone justifiable. Some of 
the cases, however, run a typically latent course. If, 
on the other hand, the nasopharyngeal disease is pri- 
mary or an accompaniment of only moderate disease 
elsewhere, complete extirpation may produce an endur- 
ing cure. 

Both the local and constitutional treatment is identi- 
cal with that outlined for the larynx. 

3. The Tumor. That the tuberculous tumor of the 
nasopharynx may be the sole apparent localization of 
the disease in the individual, as has already been shown 
to be the case with tuberculomata of the larynx and 
nose, is demonstrated by a case studied by Koschier 
(Ueb. Nasentuberculose, Wien Klin. Wochenschr., 
36-42, 1895). 

In this patient the entire post-nasal space was oc- 
cupied by a smooth, pale red tumor that was divided 
by sulci into numerous lobules. There was no ulcer- 
ation of the surface, and microscopic examination 
proved the growth to be tuberculous although at no 
time was there any evidence of pulmonary or laryngeal 
disease. 



326 NASOPHARYNGEAL TUBERCULOSIS. 

A second example of a clinically primary tumor is 
recorded by the same author but the actual primary 
nature of a lesion, however, can be definitely established 
only through thorough post-mortem examination. 

The majority of reported cases have occurred in in- 
dividuals with other and well marked signs of the dis- 
ease, i. e., those of Hajek, Schnitzler, and Avellis. Tou- 
ton's case (IV., Congress d. Beutschen dermat. Ges., 
1894) concerned a patient with lupus of the external 
and internal nose, and of the pharynx. 

The tumors have a strong resemblance to simple 
fibromata and other benign growths, and occasionally 
to gummata, and the diagnosis must rest upon the his- 
tologic examination of the tissue or upon the results 
of the tuberculin test, for they are, as a rule, entirely 
without clinical characteristics. 

In so far as treatment is concerned, the tumor is to 
be considered in the same light as other new growths 
and complete removal is to be practiced in every case, 
even when there is advancd disease of the lungs or 
other organs. Recurrences have been noted but the 
prognosis is generally favorable. 



CHAPTER XVII. 
THE PHAEYNX. 

History. 

No section of the respiratory tract succumbs so rap- 
idly to the ravages of tuberculosis when a focus is once 
established, nor leads to such hopeless suffering, as the 
pharynx. 

The infections occur in such a manner that all pre- 
ventive measures are entirely gratuitous and since 
curative and even palliative treatment, when the dis- 
ease has once gained headway, is absolutely ineffective 
in the vast majority of cases, a study of the disease can 
lead to little of practical value beyond the possibility 
of establishing an early diagnosis. 

" Primary disease of the tonsils, on the other haud, 
since it is generally of the so-called latent type, is 
amendable to surgical treatment, and hence it is ex- 
tremely important that the physician should never lose 
sight of the fact that these organs are infected in a 
considerable percentage of all cases of hyperplasia, and 
even in some that have undergone atrophy, and that 
they play a most important role in the dissemination 
of the disease to other structures. 

While this latter form is of comparatively recent 
recognition, dating from the classical paper by Dieula- 



328 PHARYNGEAL TUBERCULOSIS. 



foy, read in 1895 before the Paris Academy of Medi- 
cine, the ulcerative involvements of the pharynx were 
well described as far back as 1871. In this year Isam- 
bert first brought the subject into prominence by his 
paper entitled, "De la tubercul. miliaire aigue pharyn- 
go-laryngee." 

This communication was followed by two others, the 

one, "Nouv. faits de tuberadose miliaire de la gorge," 
published in 1876, and the other, "Confer, clin. s. I. 
mal. du larynx," in the following year. In this latter 
paper he described an apparently primary case that 
occurred in a boy four and a half years of age. 

Until this time the condition had been practically 
neglected, as is shown by Wendt (Ziemssen's Hand- 
ouch, 1874) in his statement, "Concerning the 
occurrence of tubercles in the throat, little is known." 

Aside from Isambert, the most valuable contribution 
to the literature of this period was made by B. Fran- 
kel, in 1876 (Ueb. d. Miliartuberculose d. Pharynx, Ber- 
liner Klin. Wochenschr.) 

In this thesis he said that only one case of tubercu- 
lous ulceration of the pharynx had been found in 150 
consumptive cadavers examined at the Berlin Patho- 
logical Institute, and also declared that the majority of 
the cases occur during childhood and adolescence. 

Several years before this, Navratil (Laryn. Bcitr., 
Leipzig, 1871) had reported seeing 246 cases of ulcera- 
tion of the larynx and pharynx. Of these, 162 were tu- 
berculous, 44 syphilitic, and 30 scrofulous, and in 20 
of the tuberculous patients there was ulceration of the 
pharynx. Whether or not these were all true tuber- 
culous ulcerations cannol now be determined. 



HISTOEY. 329 

Bartli (De la tuberculose du pharynx), in 1880, as 
sembled 35 cases, of which two were individuals 
over 60 years of age. Birch-Hirschfeld (Lehrbuch d. 
path. Anat., Leipzig, 1877) maintained that while tu- 
berculous ulceration of the pharynx might occur as a 
primary condition, it is almost invariably a conse- 
quence of preceding disease of other organs, and Kiis- 
sner (Ueb. prim. Tuber c. d. Gaumen, Deutsche med. 
Wochenschr., 1881) reported five primary cases, all oc- 
curing in men between the years of 34 and 56. 

Guttmann (Tuberhelbacillen in tub ere. Geschwiiren 
d. iveichen Gaumens, Deutsche med. Wochenschr., 21, 
1883) held that a primary localization of the disease 
in the pharynx never occurs. 

Tuberculosis of the tonsils, in patients suffering from 
phthisis pulmonalis, in which the lesions were scarcely 
noticeable to the naked eye and unattended by subject- 
ive symptoms, was described by Cornil and Weigert 
as early as 1884. These observations may have been 
made upon cases which would to-day be considered 
" latent." 

In the same year Strassmann (Ueb. Tubercul. d. Ton- 
sillen, Virch. Arch., Bd. XCVI, 1884) examined 21 ton- 
sils taken from subjects of tuberculosis and found 
tuberculous involvement in 15. 

The occurrence of miliary tubercles of the tonsils 
during the course of general miliary tuberculosis was 
described by Cornil and Ranvier during this same pe- 
riod (Man. d'histologie Path., 2 Edition, 1884). 

Lublinski, 1887, (Tuber c. d. Tonsillen, Monatschr, f. 
Ohrenheilk.) observed two cases of tonsillar tubercu- 
losis that were secondary to disease of both the lungs 



330 PHARYNGEAL TUBERCULOSIS. 

and larynx, while several observers, among whom may 
be mentioned Abraham, Franks, and L. Browne, 
brought forward cases of tonsillar disease that were 
apparently of a primary nature. 

The first of these (Tubercle of the Tonsil, 
Dublin Journal of Medicial Science, Oct., 1885) dem- 
onstrated the presence of beginning caseation, with ex- 
tensive tubercle formation, in the tonsil of a woman 
otherwise normal. 

Schlenker ( Unters. iiber d. Entstehung d. Tuberc. d. 
Halslymplidrusen, bes, ueber Hire Bezieh. z. Tubercul. 
d. Tonsxllen, Virch. Arch. Nr. 134, 1893) examined 24 
cadavers in order to establish the relationship between 
tonsillar, cervical-glandular and pulmonary tu- 
berculosis, and concluded that: "The cervical 
ganglia receive their infection from the tonsils, 
and that the latter receive their own from the 
lungs by means of the sputa." 

This view was upheld by Knickmann (Ueb. d. Be- 
zieli. d. Tubercidose. d. Halslymplidrusen su. d. Ton- 
sillen, Virch. Arch., Bd. CXX & CVIII, 1894) who ob- 
served tonsil tuberculosis in all of his 12 cases of cer- 
vical adenitis. 

In the following year came the epoch-making com- 
munication of Dieulafoy, in which, for the first time, 
was strikingly advanced the theory of a latent tonsil- 
lar disease not provocative of any subjective or ob- 
ject Lve macroscopic symptoms. 

His experiments were carried out by means of ton- 
si] and adenoid injections into the abdomens of guinea 
pigs, which were then examined for signs of the dis- 



ease. 



ETIOLOGY. 331 

Sixty-one tonsil inoculations were made, with the fol- 
lowing results: 6 of the pigs died with evidence of 
tuberculosis at the point of inoculation and of gen- 
eral tuberculosis; 2 showed pulmonary without local 
tuberculosis ; 4 had general sepsis and in 49 there was 
no apparent cause for death. 35 adenoid inoculations 
were made, and of these animals 3 died from both a 
local and pulmonary infection ; 4 of pulmonary without 
local disease; 3 of sepsis and 25 without any demon- 
strable lesions. 

From these results, which have been vigorously at- 
tacked, the theory of the frequent existence of a latent 
tuberculous lesion of the tonsils was evolved, and this 
assumption has been so many times substantiated by 
later and less impeachable experiments and clinical ob- 
servations, that the doctrine has now gained almost 
universal and unquestioned acceptance. 

ETIOLOGY. 

Many of the etiologic factors in connection with pha- 
ryngeal tuberculosis have been considered in studying 
the larynx, nasopharynx and nose, hence only those 
phases of the subject that are of especial importance 
or that have not been previously considered, will be 
taken up. 

Six channels of infection are recognized : (1) inhala- 
tion; (2) blood; (3) lymphatic vessels; (4) sputum; 
(5) ingesta; (6) direct extension from contiguous 
foci. 

In the vast majority of all cases the pharyngeal in- 
volvement is secondary to more or less advanced dis- 
ease of other structures, so in these instances we have 



332 PHARYNGEAL TUBERCULOSIS. 

to consider only f our of these six possible routes : sput- 
um, lymph, blood, and direct extension. 

In the primary cases infection occurs through the 
air, food or drink. 

Frequency : Pharyngeal tuberculosis is a relatively 
rare disease as can be seen from the following table : 

Author Inoculation Tests Tuberculosis 

Lewin 100 10 

Baup 45 1 

Dieulafoy 35 7 

Lartigan & Nicoll 75 12* 

Wiright 12 

Total 267 30 

Pharyngeal 
Observer Consumptives Cases 

Heintz 1226 14 

Willigk *1307 1 

Bocher 2950 12 

Frankel *150 1 

Lublinski 1600 5 

Kidd *500 7 

Phipps Institute f648 3 

Walsham *200 1 

Levy *500 67 

Agnes Memorial Sanatorium f638 1 

Author $904 39 



t Consumptives. 
t Laryngeal Cases. 
* Autopsies. 



10623 151=1.47% 



Delavan (New York Med. Journ., May 14, 1887) in 
100 cases of local tuberculosis, found the various struc- 
tures affected as follows: 

Pharynx 24 

Tongue 37 

Cheeks 22 

Uvula 8 

Nose 5 

Tonsils .'. 4 



Guttmann places the proportion of pharyngeal case 
in consumptives at 1 per cent, and Levy at 1 1-2 pe 



ETIOLOGY. 333 

cent, both of which correspond closely to the 1.47 per 
cent of the above table. 

Rosenberg (Quelques remarq. s. I. inhere, laryngee, 
Rev. de lar. 22, 1895) saw only 22 cases of pharyngeal 
tuberculosis in 22,000 patients with throat disease, 
three of which were apparently primary. 

Considering the relative infrequency of infection 
and its exposed position, it must be granted that the 
pharynx has in itself or its secretions some property 
that is extremely antagonistic to the deposit or growth 
of the tnbercle bacillus. 

This theory of an active immunity holds whether 
the majority of infections are considered as endogen- 
ous or exogenous. 

If the sputum constitutes the vehicle through which 
invasion occurs, why is it that the pharynx is so much 
less frequently affected than the larynx? The parts of 
the larynx that are covered by squamous epithelium are 
especially open to attack and yet corresponding parts 
of the pharynx, the lower posterior and lateral walls, 
where the sputum is much longer retained than in the 
larynx from whence it is soon removed by coughing, 
are only very rarely effected. 

We are equally at a loss, on the other hand, if the 
infections are ascribed to blood and lymphatic trans- 
mission, for the pharynx is richly supplied with both 
blood and lymph vessels. 

It has been abundantly proven that the tubercle ba- 
cili penetrate normal intact epithelial surfaces and 
gland ducts, and yet, while the f aucial, pharyngeal and 
lingual tonsils, and the bronchial glands are frequently 
primarily attacked, the posterior wall is rarely invaded 



334 PHARYNGEAL TUBERCULOSIS. 

in this way, — infection, when it does occur, being al- 
most always consequent upon preceding disease of 
other organs. 

To what factors, then, may this immunity be as- 
cribed? 

By some observers it has been claimed that the fre- 
quent passage of food, both solid and liquid, through 
keeping the pharyngeal wall in a state of almost con- 
stant excitation, prevents the lodgement and long re- 
tention of the bacilli at any one point, but this theory 
does not do away with the fact that during the hours 
of rest the throat is bathed almost continuously with in- 
fected pus and is left undisturbed. This explanation 
of the pharyngeal immunity has been subscribed to by 
both Schech (Krankheiten der Mundhohle, p. 219) and 
Cornet (Tuberculosis, p. 126). The latter says: 

"The inferior portion of the posterior wall of the 
pharynx, with its smooth surface and its rich secretion 
of mucus, does not afford conditions favorable to the 
growth of the tubercle bacillus, just as a much-trodden 
pathway through a meadow does not permit of the 
growth of grass, notwithstanding that the soil itself 
is in proper condition. For here, too, there is an in- 
cessant to-and-fro motion, food and drink passing 
downward, mucus travelling upward, so that the bacil- 
lus is denied the chance to gain a firm hold." 

Walsham (Channels of Infection in Tuberculosis, p. 
64-65) ascribes the immunity to the character of the 
normal secretions poured into the pharynx and to the 
normal resistance of the mucosa itself. He says: 

" I think tli at in cases of tuberculosis of the pharynx 
we must assume some alteration in the secretions 



ETIOLOGY. 335 

poured into the pharynx by the surrounding glands, or 
some alteration in the mucous membranes. A mere 
loss of its epithelial lining is not perhaps necessary for 
the penetration of the bacillus, because we now know 
that the bacillus can penetrate normal epithelium. 

"Dr. Vincent Harris has shown that the salivary 
glands (the glands examined were the parotid and 
sub-maxillary) undergo marked histological changes in 
tuberculosis. Now although tubercle of the salivary 
glands is almost unknown, nevertheless in many cases 
of the disease they undergo a distinct histological 
change. Dr. Harris says : 'Having from a number of 
cases demonstrated the occasional deficiency in the 
amount of diastatic ferment of the saliva (ptyalin) of 
phthisical patients in a late stage of the disease, I un- 
dertook the examination of the salivary glands of such 
cases obtained from the post-mortem room, with the 
view of finding out whether the condition of the secret- 
ing tissue might not account for such deficiency. The 
examination of a few cases suggested a probable ex- 
planation of the abnormal secretion, namely, that fibro- 
sis, sometimes sufficiently marked to be evident to the 
unaided eye, was not infrequently present.' 

"I have seen this condition of fibrosis also in the ton- 
sils in some cases of pulmonary tubercle. 

"I think we may sum up by saying that, owing to 
some lesion of the pharyngeal wall or to alteration of 
the secretions poured into the pharynx, tuberculosis of 
this part of the alimentary tract may result.'' 

When the defenses, whatever they may be, are weak- 
ened, infection occurs and probably in nearly all cases 
from sputal contact. It may very rarely be primary, 



336 PHAKYNGEAL TUBEKCULOSIS. 

or it may occur in the form of a miliary outbreak, 
either isolated or as part of a general miliary tubercu- 
losis ; in this type infection of course occurs through 
the blood. 

The failure of frequent lymphatic transmission may, 
perhaps, be ascribed to the poor anastomosis between 
the external and internal lymphatics. The infrequency 
of lymphatic spread from the larynx does not in any 
way militate against the theory of lymphatic infection 
of the larynx from the lungs, for, as pointed out by 
Friedrich, it is well known that in other laryngeal dis- 
eases, notably carcinoma, enlargement of the glands 
and extension to surrounding structures occur only in 
the later stages of the disease. This unique position of 
the laryngeal lymphatic system may account for the 
tendency of the disease to remain localized in the 
larynx. 

Although the process in the preponderating majority 
of all cases is a secondary one, there are a few recorded 
instances in which it appeared to be the primary focus 
and in such instances infection must be accredited to 
the inspired air or to infected food. 

The possibility of infected food causing tuberculosis 
of the tonsils has been shown by Orth and Baumgarten 
(Orth: Exper. Unters. uber die Fiitterungstuberc, 
Virchow's Archives, Vol. LXVI). They fed animals 
with tuberculous tissue, and after a short time had 
elapsed always found tuberculosis of the cervical and 
bronchia] glands, and later of the mesenteric glands, 
with demonstrable intestinal lesions. 

Apparently primary cases have been recorded by 
[saniberl ; Pluder ( 1 case) ; Schleicher ( 1 ) ; Kiissner (5 



ETIOLOGY. 337 

cases) ; Uckermann (1) ; Heymann (1) ; Wroblewski 
(1) ; Heller (1) ; Frankel (1) ; Kiier (1) ; Delavan (1) ; 
Crosslield (1) ; Clarke (1) ; Rosenberg (3) ; Roth (1) ; 
Seifert (2) ; and others. 

Clarke's case concerned a boy eighteen years of age 
who had widespread lesions of the month and almost 
total destruction of the soft palate. The lungs, on 
post-mortem examination, were found to be absolutely 
normal. 

The case reported by Isambert is not conclusive as 
the child had suffered from scrofula and obstinate 
rhinitis. 

Willis, in a paper read before the American Academy 
of Ophthalmology and Oto-Laryngology, in 1907, re- 
ferred to two cases of primary tuberculosis of the 
uvula, one a personal case, the other a patient seen by 
J. Braden Kyle. Willis's case, two years before the 
palatal tuberculosis was recognized, had been operated 
for a rectal fistula, and at that time an " ulcerated 
growth was found in the rectum, "which did not heal 
kindly. ' ' No autopsy was held. 

In addition to these channels, i. e., food, air, sputum, 
blood and lymph, we have certain instances in which 
the disease has reached the pharynx by direct exten- 
sion from the neighboring tissues. 

A case of direct spread from the larynx is described 
by Rey (Cas de plithisie laryngee avec. granulat. et 
ulcer at. tubercul. du pharynx et perforations de la 
parol laryngo-pharyngienne, Prog res Med., 18, 1885). 

This patient, a man of 40 years, had necrosis of the 
posterior part of the cricoid cartilage, and from this 
focus the process spread to the pharynx. 



338 PHARYNGEAL TUBERCULOSIS. 

V. Jaruntowski (Z. Aetiol. d. tubercul. Affection en 
d. Mundlwhle, Munch, med. Wochenschr., 18, 1895) 
described a case in which the disease reached the an- 
terior pillar of the tonsil from a lesion of the cheek. 

According to Lori (D. durch, andenv. Erkrank. bed. 
Veranderung d. Rachens. d. Kehlkopfes u. d. Luftro 
lire 1885) there are sometimes found, in cases of menin- 
gitis tuberculosa, miliary tubercles of the pharyngeal 
mucosa that are unattended by subjective symptoms. 

I have seen one case in which destruction of the 
soft palate, with subsequent extension to the pillars 
and tonsils, resulted from ulceration of the floor of the 
nose and upper surface of the palate. 

Age : The disease does not show any limitations in 
the age extremes of those attacked but the majority of 
the cases occur in the period between and including 
puberty and late adolescence. Although neither ex- 
treme of age is exempt, the condition is much more fre- 
quently met with in the very young than in those of ad- 
vanced years. 

V. Santvoord (Tuberculosis of the Lungs, &c, New 
York Medical Record, March 14, 1885) records a case 
occurring in an infant of 18 months, and reference lias 
already been made to Isambert's case of primary pha- 
ryngitis in a boy of four and one-half years. All of 
Abercrbmbies ' three cases (On three Cases of Ac. Tu- 
berc. Ulc. of Fauces, British Med. Journal, Nov. 13, 
1886) occurred in young children, and P. Schotz 
(Deutsche medicinische Wochenschrift, Oct. 15, 190.°)) 
saw two cases in children o!' eighl and ten years of age. 

Of 35 cases assembled by l'arlli, two were over 60 



ESOPHAGEAL LESIONS. 339 

years of age. The great majority have occurred be- 
tween the years of 20 and 35. 

In the author's series of 39 cases there was but one 
under 20 years, a boy of 11 with widespread involve- 
ment of the pillars and posterior wall, and only one was 
over 36 years, a woman of 47. Nearly all occurred be- 
tween the ages of 22 and 30, and in all the process was 
secondary to disease of the lungs, or lungs and other 
organs. 

Sex: Pharyngeal tuberculosis is much more com- 
mon in males than in females, the disproportion being 
considerably greater than in laryngeal tuberculosis and 
almost the exact opposite of what obtains in the nose. 
A study of all available reports gives an approximate 
proportion of four to one. There seems to be no ade- 
quate explanation of this greater vulnerability on the 
part of the male, and it bears no relation to the fre- 
quency with which the two sexes are attacked by pul- 
monary phthisis. Twenty-eight of the thirty-nine pa- 
tients seen by the author were men. 

Esophagus : It has been seen that in the respiratory 
tract the tuberculous infections decrease markedly in 
frequency as we ascend from the lungs to the external 
openings, but in the upper alimentary tract the exact 
converse obtains and the esophagus occupies some- 
what the same position as the nose. 

Up to the year 1898, Cone (Milnchener medicinishe 
Wochenschr., Nr. 5, 1898) was able to assemble but 48 
cases and only a few additional ones have been since 
reported. The reason for this infrequency is readily 
seen when the conformation of the tube and its physio- 
logical functions are studied. 



340 PHARYNGEAL TUBERCULOSIS. 

The smooth, stratified, pavement epithelial surface 
of the canal ; the even caliber of the tube, presenting no 
points of sudden shelving (the several points of nar- 
rowing are not abrupt) such as the cords, arytenoids, 
and epiglottis offer in the larynx ; and the lack of any 
aggregations of lymphatic tissue with its favoring 
crypts and follicles, such as exist in the nasopharynx 
and pharynx, and at the base of the tongue, offer few 
opportunities for the lodgement and penetration of the 
bacilli. 

Although tuberculous sputum is frequently swal- 
lowed by consumptives and bacilli are often passed 
through the tube in infected food, they are so thorough- 
ly enveloped by the mucilaginous-like secretions that 
they can scarcely come into direct contact with the mu- 
cosa, particularly as the larger masses are not ar- 
rested, even momentarily, in their passage to the 
stomach. Even the smaller masses that do adhere to 
the smooth walls are quickly washed away by the pass- 
ing food and drink. 

That these are the main protective agencies is wit- 
nessed by the fact that a primary infection of the 
esophagus is practically unknown; — nearly all record- 
ed cases have occurred as the result of direct extension 
from contiguous tissues. 

In a few instances the tuberculous process has been 
grafted upon a pre-existing lesion, such as syphilis, 
carcinoma or traumatic ulcers. Abrasions of the ran- 
a, be their character what they may, offer a favor- 
able nidus for the development of the bacilli, but a 
primary infection of the uninjured tube has so far 
not been observed. 



PLATE XXIV. 



Fig. 76. Ulceration of the esophagus secondary to exten- 
sive disease of the larynx. 



PLATE XXIV. 



Fig. 76. Tuberculous ulceration of the esophagus. 




(^NX*KL 



Fig. 76. 



PLATE XXIV. 



ESOPHAGEAL LESIONS. 341 

In a patient who had drunk caustic potash and had in 
consequence many cicatrices of the esophagus, Breus 
(Tuberculose Ulcer, des Pharynx, Oesophagus und 
Magens nach Kalilaugenatzung, Wiener. Med. Woch- 
enschr., Nr. II, 1878) found at autopsy a number of tu- 
berculous ulcers in the pharynx, esophagus and stom- 
ach, and Kundrat (Wiener med. Wochenschr. Bd. 
XXXIV, Nos. 6 & 7, 1884) saw a similar case due to 
the drinking of sulphuric acid. 

Zemann (Tuberculose des Oesophagus, Anz. d. Ges. 
d. Ae. in Wien, No. 31, 1886) saw one case of a like 
nature, while Eppinger (Ueb. Tuberculose des Magens 
und des Oesophagus, Prager med. Wochenschrift, Nos. 
51 & 52, 1881) observed a woman in whom miliary tu- 
bercles and ulcers were found throughout the entire 
extent of the esophagus, which before cleansing had 
been almost entirely occluded by mould. 

The development of tuberculosis upon a carcinoma- 
tous base has been described by a number of observers, 
i. e., Lubarsch, Pepper, Edsall, Zenker, and Cordua. 

Beck and Zenker have reported cases in which the 
esophageal ulceration advanced subepithelially from 
the pharyngo-laryngeal portion of the gullet, and Maz- 
zotti (Belle alterazioni dell esofago nella tuberculosi, 
Rivista Clinica, 1, 1885) had two cases in which the 
esophageal ulcers were associated with intestinal tu- 
berculosis. In one case there were some simple de- 
nudations of the gullet through which infection un- 
doubtedly occurred. 

Mazzoti observed another case, a boy of 10 years, 
who had a caseating bronchial gland and general mil- 
iary tuberculosis. 



342 PHARYNGEAL TUBERCULOSIS. 

In the case pictured in Plate XXIV, Fig. 76, the in- 
fection appeared to have originated in the manner de- 
scribed by Beck and Zenker, that is, by subepithelial 
extension from the pharyngo-laryngeal portion of the 
gullet. 

The entire posterior wall in the vicinity of the up- 
per aperture was filled with submucous tubercles, 
which, at a number of points, had advanced to ulcera- 
tion. From this point downwards they decreased rap- 
idly in numbers, the final aggregation being not more 
than one inch below the aperture. 

Two isolated ulcers were found somewhat lower, 
about one inch below the final cluster. 

The more frequent route of infection is from the 
outer surface of the tube and particularly from its 
anterior border, where the wall becomes fused with 
broken down bronchial or cervical glands, with subse- 
quent perforation and extension of the process beneath 
or in the epithelium. 

Bartlett (Ann. Otol. Rli'ui. and Lavyngol., Nov.. 
1899) reports two such cases; in one there was one fis- 
tula, in the other fiYQ, leading to as many different peri- 
bronchial and posterior mediastinal glands. 

AYliile such a perforation almost always results in a 
spread of the disease to the lining of the tube, the pro- 
cess sometimes stops at this point and the perforation 
may close spontaneously. Cases of perforation with- 
out esophageal foci are recorded by Penrose, Neumann, 
Poland, Nowak, Barry, Eanot, and Volcker! 

The condition often runs a symptomless course and 
it is probably due to this factor, us well us to tlie dif- 



THE FAUCIAL TONSILS. 343 

ficulty of diagnosis during life, that sncli a small num- 
ber of cases are recorded. 

Fancied Tonsils : The study of tonsillar tuberculosis 
may be said to date from the thesis of Dieulafoy en- 
titled, "Latent Tuberculosis of the Three Tonsils," 
(1895) in which he reported the results of numerous 
inoculations of guinea pigs with portions of hyper- 
plastic tonsils and adenoid vegetations taken from in- 
dividuals presumably non-tuberculous, and from which 
he drew the following conclusions : 

"There is another form of tuberculosis of the Pala- 
to-nasopharynx which is much more frequent. If this 
form to which I allude has for a long time passed un- 
perceived, it is because it does not correspond to any 
of the forms of pharyngeal tubercle just sketched. This 
form is neither ulcerous nor granular; it is not at all 
painful ; it remains unknown until the day when it re- 
veals itself by certain functional troubles ; it is benign 
in appearance, but is none the less formidable, for it is 
sometimes the portal of entrance of a generalized tu- 
berculosis and of pulmonary phthisis. 

"This tuberculosis is torpid, concealed, almost lat- 
ent, having as its favorite seat the lymphoid tissue of 
the naso-pharynx. It reveals itself by a greater or less 
enlargement of this tissue, by a hypertrophy of one or 
more of the tonsillar structures. As concerns the pha- 
ryngeal tonsil, it confounds itself with the condition 
known as adenoid vegetations ; as concerns the faucial 
tonsils, with the condition known as simple hypertro- 
phy. Inspection in no wise reveals the nature of the 
lesion. It does not present, I repeat, on inspection, 



344 PHAKYXGEAL TUCEKCULOSIS. 

either granulations or ulcerations, only simple hyper- 
trophy, with the usual symptoms of the latter. ' ' 

Because he had made no histologic examination of 
the tonsils used for inoculation, his work was severely 
criticized, and it was advanced that virulent bacilli 
might have been concealed within the tonsillar crypts 
without there having been any actual tuberculosis of 
the glands themselves. 

Less objectionable experiments by later observers, 
however, have amply supported all his conclusions. 

Walsham (Channels of Infection in Tuberculosis, 
pgs. 44-62) made two classes of experiments: first, ex- 
amination of tonsils, cervical glands, and lingual 
glands from subjects of tuberculosis examined post- 
mortem, and second, examination of portions of ton- 
sils and adenoid vegetations removed from the living 
body. 

(1.) In thirty-four consecutive post-mortems, the 
tonsils were found tuberculous in twenty. In the ma- 
jority of the cases the tonsils were atrophied; in two 
there was slight hypertrophy and in none had there 
been any subjective symptoms referable to the throat. 

(2). All examinations negative. 

Other observers, however, have found primary ton- 
sillar tubercles in a considerable percentage of their 
cases. Ruge, in 18 cases, found definite signs of tu- 
berculosis in six. 

Baup gives a table of 84] tonsils examined by dif- 
ferent investigators, of which 53 (or about six per 
cent) showed tuberculous involvement. 

Rethi (Wiener Klin. Rundschau, July 1, 1900) found 



THE FATJCIAL. TONSILS. 345 

bacilli in six of 100 hypertrophied tonsils taken from 
subjects showing no signs of tuberculosis. 

Von Schreiber (Deutsche Med. Wochenschr., May 
25, 1889) examined a large number of tonsils taken 
from apparently sound indiivduals and found tuber- 
cles in three. 

C. M. Robertson (Journal American Med. Assoc, 
Nov. 24, 1906) found 8 per cent of 232 tonsils, removed 
from living patients, to be tuberculous. 

G. B. Wood (Journ. Amer. Med. Assoc, May 6, 
1905) concludes, from his investigations and the pub- 
lished records of 1671 cases of hypertrophied tonsils, 
that at least 5 per cent of all hypertrophied pharyngeal 
tonsils conceal latent tuberculous lesions, but that the 
faucial tonsils are more rarely involved. 

In individuals with tuberculosis of other organs ton- 
sillar involvements are the rule. In addition to the 
figures already cited we have the statistics of Strass- 
mann and Kriickmann. 

The former found the tonsils affected in fifteen of 
twenty-one cases examined, and the latter twelve times 
in twelve cases of cervicallymphadenitis, and in forty- 
eight of fifty cases of advanced phthisis. In thirty- 
four cases of moderate pulmonary involvement they 
were affected in only six. 

Schlenker found eight cases of bilateral tonsillar 
involvement, and one of unilateral, in nine consump- 
tives having advanced disease. In nine other cases, 
with only moderate pulmonary involvement, the tonsils 
were affected in two, and in live children with either 
mild or only moderately advanced disease of the lungs, 
the tonsils were tuberculous in three. 



346 PHARYNGEAL TUBERCULOSIS. 

Schlesinger found tonsillar tuberculosis in twelve of 
thirteen cases of florid consumption occurring in young 
children, while both Kiirckmann and Orth saw cases 
of primary tuberculosis of the faucial tonsils of chil- 
dren suffering from diphtheria, in whom the lungs 
were entirely normal. Euge found tonsillar tuberculo- 
sis in every one of five cases of severe phthisis. 

Dmochowski found them involved in all of fifteen 
cases, in none of which, however, had there been airy 
macroscopic evidence of the disease. 

Of the tonsils of 136 cases of pulmonary tubercu- 
losis assembled by Wood from the reports of various 
experimenters, 94 (69 per cent) showed tuberculous 
involvement. In 47 of his personal cases of this char- 
acter they were diseased in 44. 

A condition similar to this latent tonsillar tubercu- 
losis is found in the lateral folds of the pharynx, where, 
according to Cordes, a new elongated tonsil is formed ; 
there is a formation, not only of lymphoid tissue but 
of actual crypts and follicles as well. 

Sokolowski examined the granular tissue of the 
pharynx and lateral folds of 13 consumptives and 
found latent tubercles in eight, or 61 1-2 per cent of the 
cases. 

The lingual tonsil was found to be tuberculous in 
nine of fifteen consumptives examined by Dmochowski. 

In those cases of secondary infection the bacillus 
niiisi have been deposited by the sputum in tin 1 ma- 
jority of cases, in others by the blood or lympha- 
tic current, but in those in whom the disease is local- 
ized in the tonsil, infection occurs through primary de- 
posil al this point by the air or ingesta. 



THE FAUCIAL TONSILS. 347 

Schlesinger (D. Tnhercul. d. Tonsillen. b. Kindern. 
Berl. Klinik. 99, 1896) records a case in which the in- 
fection travelled, via the lymphatics, from a focus in 
the petrous portion of the temporal bone to the cervi- 
cal glands, and from them to the tonsils. 

Retrograde infection from the cervical glands has 
been proven in a considerable number of cases. 

Since the bacillus is known to pass through intact 
mucous membranes without necessarily leaving trace 
of its passage, and can pass on into other and more 
vulnerable tissues, the tonsils, in view of the consider- 
able percentage of cases in which tubercles are found 
without other demonstrable foci, assume considerable 
importance as a portal through which infections gain 
a foothold. 

A direct connection between these tonsillar infec- 
tions and cervical adenitis has been shown in a large 
series of cases. From his own investigations and a 
review of the literature, Walsham concludes : 

(1.) That the tonsils, instead of being almost im- 
mune from tuberculous disease, are very frequently 
affected. 

(2). That tubercle may be primary in the tonsil. 

(3). That the tonsils are very frequently affected 
secondarily in persons suffering with chronic tuber- 
culosis. 

(4). That when the tonsils are tuberculous, the cer- 
vical glands receiving the lymphatics from these or- 
gans are also frequently affected with tubercle. 

(5). That the follicular glands at the base of the 
tongue are occasionally found tuberculous. 



348 PHARYNGEAL TUBERCULOSIS. 

(6). That tonsils may be affected from without or 
through the blood stream in acnte miliary tubercu- 
losis. 

The conditions favoring the entrance of the bacilli 
into the tonsils, their retention and development, have 
been shown on pages 311 and 313, so these factors, 
holding true in respect to the faucial lymphoid tissue 
as well, need not be reiterated. There remain to be 
quoted only some additional facts regarding the part 
this tissue plays in the further dissemination of the 
disease. 

Tuberculosis may develop at any point and in any 
tissue in which the bacillus finds lodgement, following 
which there is involvement of the nearest lymph 
glands. When these have succumbed, the process ex- 
tends to the next communicating chain and in time, by 
continuous progression, the disease may reach the 
bronchial glands, mediastinal glands and the pleural 
apices. 

This source of infection has been carefully investi- 
gated by different observers with different results and 
conclusions. 

Grogler injected the tonsils of living animals with 
India ink and was able to demonstrate its passage, via 
the lymphatics, into the pleural apices and bronchial 
glands. From the case reports of various observers 
he also found that 14.3 per cent of patients with tuber- 
culous cervical lymphadenitis developed tuberculosis 
of the pleura. 

Beitzke attacked these experiments after extensive 
anatomical and experimental studies, and summarized 
as follows : 



THE FAUCIAL TONSILS. 349 

"(1). There exist no lymph vessels leading from 
the chain of cervical lymph glands to the bronchial 
glands. 

"(2).- Tuberculous infiltration of the lungs from 
cervical lymph glands can take place only through the 
lymphatic trunk and the venous system. 

" (3). This path of infection, at least in children, is 
without any practical import. The infection of the 
lungs, and hence the bronchial glands, in children as 
a rule takes place through aspiration of the tubercle 
bacillus into the bronchi; a descending tuberculosis 
may be present incidentally. 

{i (4). The aspirated bacilli may be in the respired 
air but they come from the mouth where they may have 
gained access by food or by contact/' 

Wood's experiments support Beitzke's claim con- 
cerning the connection between the supraclavicular 
lymph glands and those higher up in the neck but, on 
the other hand, he showed that : 

' ' In children the number and arrangement is very ir- 
regular, and that the pleural apices come into fairly 
close relation not only with the supraclavicular glands 
but also with the extreme lower portion of the greater 
vessels of the neck. 

• "The deep lateral chain of the neck extends down- 
ward along these vessels, and if there should be a node 
situated in the lower part of the neck, as sometimes oc- 
curs, it is conceivable that the tuberculosis of this node 
may infect the pleural apices directly by continuity of 
structure. ' ' 

In a previous chapter it has been shown that laryn- 



350 PHARYNGEAL TUBERCULOSIS. 

geal infection in some cases lias its apparent origin in 
a glandular focus. 

Inoculation experiments by Cornet show how gener- 
alized infections sometimes result from induced foci 
in the tonsils, posterior pharyngeal wall, and mouth. 

Seven animals were inoculated in the lateral pockets 
of the mouth, two in the tonsils, two in the tongue, and 
two in the posterior pharynx. In every case there en- 
sued cheesy degeneration of the submental, sublingual 
and cervical glands, and in some instances nodules 
appeared in the lungs, and later on in the spleen. An 
ulcer generally occurred, after about three weeks, at 
the point of inoculation, although in some instances no 
local changes were observable. 

A clinical case of great interest in this connection is 
recorded by Koplik (Amer. Journal Med. Sciences, 
Nov., 1903). A child who had died of acute general 
miliary tuberculosis showed on autopsy that the only 
old cheesy foci were located in the tonsil, strong evi- 
dence that the disease had originated at that point. 

Walsham refers to a number of somewhat parallel 
cases, in which all the post-mortem evidence pointed to 
lesions of the tonsils as the foci of dissemination. 

While we as yet have little data of definite value con- 
cerning the influence of the tonsils and glands in caus- 
ing generalized tuberculosis, all the work that has 
been done points to the fact that they are of consider- 
able etiologic importance 4 . 

The Intent foci show slight tendency to destruction 
or cheesy degeneration, although ulceration does ex- 
ceptionally result. As a rule they gradually disappear 



PLATE XXV. 



Fig. 77. Edema of the pillars of the tonsils, with small 
group of incipient tubercules on the soft palate 



PLATE XXV. 



Fro. 77 '. Infiltration and edema of the pillars of the tonsils. 




(av/m 



Fig. 77. 



PLATE XXV. 



SUBJECTIVE SYMPTOMS. 351 

through the process of retrograde metamorphosis 
which is a characteristic of all tonsillar tissue. 

Apparently primary tuberculosis of the tonsils, of 
an ulcerative type, has been observed in a considerable 
number of instances. The two cases recorded by Orth 
and Kurckmann in which the condition was present in 
children suffering from diphtheria, have already been 
mentioned. 

Abraham (Dublin Journal of Med. Science, Oct., 
1885) recorded a case of tonsillar ulceration occurring 
in a woman in whom there were no other demonstra- 
ble foci, and Ruge observed a like condition in an eight- 
een year old girl otherwise normal. 

In Lennox Browne's case, prevously referred to, 
there was tuberculous ulceration of the left tonsil but 
neither the lungs nor larynx was affected. Ozeki (In- 
temat. Centralb. f. Laryn., Sept., 1900) reports two 
personal cases. 

A number of other isolated cases are on record. 

SYMPTOMS. 

Subjective : Latent tonsillar tuberculosis presents 
no subjective symptoms, and when ulceration has oc- 
curred the manifestations are identical _with those 
evoked by a breaking down of the other segments of 
the pharynx, hence the clinical picture may be pre- 
sented without an attempt to consider each segment by 
itself. 

The one, great, predominant symptom of pharyngeal 
tuberculosis is pain. In the very early days of the 
outbreak there may be nothing more than a sensation 
of tickling, of constriction, or as of a foreign body, but 



352 PHAKYNGEAL TUBERCULOSIS. 

this rapidly changes to one of actual pain, unremitting 
and severe, with extreme exacerbations upon all at- 
tempts at swallowing food or mucus, and upon use of 
the voice. Great quantities of mucus are poured out 
which, thick and tenacious in character, add greatly 
to the sufferer's discomfort. The pain is greatest in 
the pharynx but extends in lancinating attacks to the 
ears by transference through the nerves, i. e., the va- 
gus and glossopharyngeus and its tympanic branch, 
Jacobson's nerve. 

The pain increases rapidly until, generally within a 
comparatively few days, it becomes so severe that the 
patient voluntarily abstains from all food and drink, 
preferring starvation to the agony attendant upon 
swallowing. Lesions of the palate may, exceptionally, 
run an almost painless course and I have seen one case 
of pharyngeal ulceration that occasioned nothing more 
than moderate discomfort. 

Regurgitation of food, both liquid and solid, is an 
almost invariable result of advanced disease, be- 
cause of the imperfect closure of the naso-pharynx by 
the palate. 

This failure of the palate to perform its functions 
gives to the voice a hard, so-called "palatal" quality, 
closely resembling that so characteristic of other pain- 
ful affections of the tonsils and pillars, i. e., peritonsil- 
lar abscess, plegmon, &c. 

The temperature is usually somewhat elevated and 
there is rapid loss of strength and weight, with a gen- 
eral increase of activity in all other existing foci. 

The pyrexia is due not so much to the pharynx itself 

as to the accompanying disease of the lungs or other in- 



PLATE XXVI. 



Fig. 78. General ulceration of the palate, extending for- 
ward upon the hard palate. Uvula infiltrated, 
with crenated borders. 



PLATE XXVI. 



Fig. 78. Extensive ulceration of the palate. 





(*^.N^O». t_ I— X — CD <sl 



Fig. 78. 



PLATE XXVI, 



OBJECTIVE SYMPTOMS. 353 

fected organs, which is always more or less aggravated 
by the malnutrition, pain, cough and restlessness con- 
sequent upon the pharyngeal outbreak. 

In primary infections of the pharynx the tempera- 
ture is rarely elevated to any great extent, although it 
may rise one or two degrees. 

Several severe cases have been noted in which no in- 
crease whatsoever occurred, but, on the other hand, 
hyperpyrexia has occurred in a number of instances. 

Mackenzie had one case in which the temperature 
ranged as high as 104 degrees, and upon one occasion 
rose to 106 degrees. 

In one of Frankel's cases the temperature curve re- 
sembled that of typhoid and in another it rose to 107.06 
degrees. 

The breath is invariably foul but this is undoubtedly 
due, in large part, to the accompanying pulmonic dis- 
ease. 

OBJECTIVE SYMPTOMS. 

The macroscopic images in pharyngeal tuberculosis 
are usually quite characteristic, for by the time the 
subjective symptoms are sufficiently pronounced to di- 
rect attention to the throat, the process has usually ad- 
vanced so far that no doubt as to the diagnosis can 
arise. 

The process is generally so fulminant that little op- 
portunity is afforded of studying the condition in its 
incipient stages (congestion and circumscribed infiltra- 
tion) such as we see in the larynx, and we have to 
deal, as a rule, with an already widespread ulceration 
or advanced tubercle or miliary formation. 



354 PHAKYNGEAL TUBERCULOSIS. 

Uncomplicated diffuse infiltration is the rarest of all 
forms and seldom comes to observation, owing to the 
fact that the parts are subject to almost constant mo- 
tion and the thermic and chemical irritation by the in- 
gesta and secretions, with consequent ulceration at a 
very early period. 

The infiltrate tends to spread more deeply into the 
tissue than in other parts, and because of the almost 
constant presence of some edema, is more transparent 
and colorless in appearance. 

The most vulnerable points are the pillars of the ton- 
sils and in these localities the edematous infiltration 
may be so great as to produce enormous thickening, 
sufficient at times to absolutely destroy the normal con- 
tour of the pharynx. 

They become gelatinous in appearance, are marked- 
ly convex in both diameters, and may be covered by 
either a smooth or warty mucosa which contains nu- 
merous submucous miliary nodules. Such a case is 
shown in Plate XXV., Fig. 77. 

This patient, a man of 35, had had both pulmonary 
and laryngeal tuberculosis for about one year when 
the palatal infiltration appeared. The condition in 
both the lungs and larynx was rapidly nearing the 
stage of arrest, when he developed some dysphagia 
and odynophagia. The posterior pillars of both ton- 
sils were found to be enormously infiltrated, making 
contact with the anterior folds and completely hiding 
the underlying tonsils. 

The uvula was congested but not edematous, and 
on the right side the soft palate, immediately above 
the anterior pillar, showed several incipient miliary 



PLATE XXVII 



Fig. 79. Ulceration of the tonsil involving the anterior 
and posterior pillars, showing characteristic pro- 
fuse granulation tissue. 



PLATE XXVII. 



Fig. 79. Tuberculosis of the tonsil. 




Fig. 79. 



PLATE XXVII. 



OBJECTIVE SYMPTOMS. 355 

tubercles. The swellings had a transparent, gelatinous 
appearance, and the mucosa was smooth and glisten- 
ing. 

Within a few days the entire mass broke down and 
became covered with innumerable spots of ulceration, 
varying in size from a pinpoint to an almond seed, and 
in less than two weeks the process had extended over 
the entire soft palate and uvula. 

This condition is shown in Plate XXVI., Fig. 78, 
made fifteen days after the preceding illustration. 

In some rare cases the entire soft palate, uvula and 
pillars are infiltrated to such an extent that they be- 
come board-like in consistency, dense, firm, rigid and 
unyielding. 

At the present time the writer has a patient under 
observation in whom all of these structures are so infil- 
trated that they are absolutely immobile. The soft 
palate is extensively ulcerated, but neither the uvula 
nor pillars have as yet given way to the constantly in- 
creasing pressure of the infiltrate, and yet the tip of 
the uvula can scarcely be moved, and the swollen tis- 
sues encroach so much upon the pharyngeal aperture 
that there is not sufficient space for the introduction 
of the smallest mirror. 

In the more common form of the disease we see a 
swollen and more or less anemic mucous membrane, 
through the surface of which glisten numerous small 
gray or yellow tubercles. The mucosa surrounding 
these groups may be slightly inflamed, although as a 
rule it has a pale and lifeless appearance. 

The tubercles rapidly disintegrate and form super- 
fiscal ulcers within a period of a few days to two or 



356 PHAKYNGEAL TUBERCULOSIS. 

three weeks. These are absolutely pathognomonic and 
their favored sites are the soft palate and the uvula, 
and then the tonsils and posterior wall. 

The resultant ulcers are lenticular in form and ex- 
tend toward the periphery rather than into the deeper 
structures; the edges are irregular, "mouse" or 
"worm" eaten, and merge gradually into normal tis- 
sue, although they may occasionally be slightly infil- 
trated or undermined. An areole of moderate hype- 
remia may or may not be present. 

The infiltration is generally so slight as to be scarce- 
ly appreciable, and the floor is dotted with minute pale- 
red granulations which are commonly obscured by a 
tenacious dirty yellow secretion. These are especially 
profuse upon the tonsils and posterior wall. (Plate 
XXVIL, Fig. 79). 

In some instances the ulcers are covered by a de- 
posit that bears a strong resemblance to the membrane 
formed in diphtheria, and when this becomes confluent 
and covers large areas of the tonsils and posterior 
wall, it may give rise to some difficulties in diagnoss, 
especially as in this type there is high fever, severe 
pain, prostraton, and occasionally some dyspnea. 

In the immediate vicinity of the ulcer minute miliary 
tubercles usually appear, which soon disintegrate, 
causing rapid extension to all contiguous parts. 

The occurrence of a true miliary tuberculosis of the 
pharynx is extremely rare, and as a rule is a manifes- 
tation of a genera] miliary tuberculosis but the pha- 
rynx is occasionally the only site of the disease. 

I have seen two cases in which the outbreak occurred 



PLATE XXVIII. 



Fig. 80. Extensive tuberculous ulceration of the pharynx, 
pillars, uvula and palate. 



PLATE XXVIII. 



Fig. 80. Tuberculosis of the pharynx, pillars, uvula and 
palate. 





(^■NX^Qs.l—l— -r" — osl 



Fig- 80. 



PLATE XXVIII, 



OBJECTIVE SYMPTOMS. 357 

in association with a miliary laryngitis. One of these 
recovered, the other died within two months. 

Other cases have been described by Lori, Cadier 
Kher, Rethi, Catti, Letulle, Frankel, and a few other 
observers. 

On the posterior walls the nlcers may be round, oval 
or irregular, but occasionally they assume a pro- 
nounced stellate form. When the tonsil is extensively 
involved, large portions of the organ may melt away 
with great rapidity ; at certain points the ulceration ex- 
tends to the basal membrane, while the tissue in the 
intermediate spaces is so friable and granular that it 
can be torn away, piece by piece, with the greatest 
ease. In these cases the tonsil appears as though it 
were the seat of a virulent gangrene, and severe bleed- 
ing may occur. Ordinarily the tuberculous process is 
not productive of hemorrhages, and in the case report- 
ed by Frankel in which there was much bleeding the 
tuberculosis was complicated by a mercurial stoma- 
titis. 

The uvula is frequently affected at an early stage of 
the disease. It may be thickened to from two to five 
times its normal size by a collection of numerous, hard, 
wart-like tubercles, giving it the so-called ''thumb'' 
shape. In other cases small yellow miliary tubercles 
or minute ulcers, resembling the spots produced in her- 
pes after the breaking down of the vesicles, dot its en- 
tire surface. 

In time many of the various areas become confluent 
and the throat appears as though it were covered by 
one immense ulcer or adherent membrane, that extends 
in some instances into the naso-pharynx, in others to 



358 PHARYNGEAL TUBERCULOSIS. 

the tongue and larynx, or the cheeks and gums. (Plate 
XXVIII, Fig. 80.) 

Death usually intervenes before there is time for 
much actual loss of tissue — except in cases of tonsillar 
ulceration — but sometimes a large part of the palate or 
uvula disappears. 

Cicatricial bands between the palate and posterior 
pharyngeal wall, such as are seen after syphilitic dis- 
ease, rarely form, owing to the failure of any perma- 
nent reparative efforts. Kraus, however, (Nothnagel's 
Handbuch, XVI, I, Th. 1, Abth., p. 276) reports sev- 
eral such cases. 

Perforations of the palate have been observed in 
a small number of instances and are of especial import- 
ance because of the likelihood of their being confused 
with syphilis. 

Comparatively few such cases nave been recorded 
and these embrace lesions of both the hard and soft 
palate. 

Ulceration not leading to perforation, on the other 
hand, is fairly frequent, and in a few well authenticated 
cases seem to have been the primary localization of the 
disease. (Plate XXIX., Fig. 81). 

Kussner saw four such cases, one was reported by 
Kessler, and one by Uckermann. This last case (Uck- 
ennann's) was completely cured. 

According to Guttmann, nearly one per cent of the 
rases of phthisis seen by him had tuberculous ulcera- 
tion <>F the palate and soft palate, and of the 114 cases 
of local tuberculosis reported by Delavan (New York 
Med. Jour., May 14, 1887) 8 had ulceration of the 
velum. 






PLATE XXIX. 

Fig. 81. Circumscribed ulceration of the soft palate. 



PLATE XXIX. 



Fig. 81. Circumscribed ulceration of the soft palate. 













C^X^KI^L- X— PCsl 



Tig. 81. 



PLATE XXIX. 



OBJECTIVE SYMPTOMS. 359 

Wagner saw two patients with tuberculosis of the 
soft palate, both of whom had had syphilis, and Agua- 
nno saw tuberculosis become grafted upon a specific 
ulcer of the velum. 

Newcomb, in 1904 (Tuberculosis of the Pharynx, 
Laryngoscope, June, 1904), was able to find but 11 
cases in which perforation had occurred, 10 of which 
had been assembled by Grogler. Of these ten cases, 
eight occurred in patients with well marked disease of 
the lungs or larynx. 

In one case of Kayser's (Monatschr. f. Ohrenheilk., 
8-9, 1905) the perforation affected the left anterior 
palatine arch, and one case is recorded in which ne- 
crosis of the hard palate resulted, necessitating exten- 
sive removal of the bone. 

Barbier (Journ. Laryn., London, April 2, 1899) saw 
one case of perforation of the soft palate that fol- 
lowed a severe attack of influenza. 

The process is extremely sluggish, and examination 
reveals an inflammatory areola enclosing a bloody and 
purulent ulcer, dotted here and there by numerous pale 
or red granulations. The borders are irregular, super- 
ficial and mouse-eaten. The ulcer gradually increases 
in depth without much lateral spread, until perfora- 
tion results. 

The opening is sinuous in form and lies at the bot- 
tom of a deep and irregular fissure or cleft, and is al- 
ways solitary. 

Aside from these acute and sub-acute lesions, due to 
direct infection of the pharyngeal tissues, there is in 
addition an essentially chronic process in which the 
X)Osterior pharynx is involved by extension from a 



360 PHARYNGEAL TUBERCULOSIS. 

neighboring focns in the vertebral column. This ap- 
pears in the pharynx as a cold abscess, and the symp- 
toms are those due to the vertebral disease associated 
with a large fluctuating tumor in the retropharynx, 
the location of which depends upon the particular ver- 
terba affected. In very young children the abscess is 
generally confined to one side — a central localization is 
extremely rare — and it may be located either high up 
behind the velum palati or low down in the pharynx. 

The symptoms, as a rule, are insidious. 

There is little attendant inflammation and attention 
is generally first drawn to the throat by the develop- 
ment of dysphagia and dyspnea. The voice has a 
palatal quality, the so-called "Crie de Canard" of 
Eeigenier, and there is a hacking cough. There may 
or may not be pain but there is always some tender- 
ness on pressure. 

Adenitis of the cervical and sub-maxillary glands 
may occur in all forms of pharyngeal tuberculosis, but 
even the severer types may be unaccompanied by any 
signs of enlargement or sensitiveness. It may occur 
either early or late in the course of the disease, the de- 
gree of pharyngeal involvement seemingly bearing no 
relation to the frequency of glandular infections. 

Tuberculomata do not occur in the pharynx ; at least 
they have not as yet been observed, although Avellis 
(Deutsche med. Wochensch., Nr. 32 and 33, 1891) de- 
scribes their occurrence on the posterior surface of 
the uvula. 

Masses of granulation tissue resembling tubercu- 
lomata have occurred upon the tonsils and uvula, and 
in the case of Schnitzler's, already described, the in 



PLATE XXX. 



Fig. 82. Triple perforation of the soft palate and anterior 
pillar of syphilitic origin, in a patient with pul- 
monary tuberculosis (Case seen by courtesy of 
Dr. D. S. Newman). 



PLATE XXX. 



Fig. 82. Syphilitic perforations of the palate. 




(^X^*M-L--y — p<3l 



Fig. 82. 



PLATE XXX. 



DIAGNOSIS. 361 

jection of tuberculin caused the eruption of numerous 
miliary tubercles that became aggregated in tumor-like 
masses upon the posterior pharyngeal wall and within 
the naso-pharynx. These, however, are not instances 
of true tuberculomata, which, in the strict meaning of 
the term, are tumor-like growths not preceded nor ac- 
companied by ulceration. 

DIAGNOSIS. 

A tuberculous lesion of the pharynx is so character- 
istic in appearance that, once seen, it can scarcely be 
mistaken for any other condition. 

Certain of the rarer types, however, and atypical 
forms of the more common varieties may give rise to 
some temporary confusion. 

First in the list of diseases with which it may be 
confused is syphilis. In their typical manifestations 
no points of similarity exist; the lesions of both are 
pathogonomonic, and the extra-laryngeal symptoms 
are so constant and clear that a mistake in differentia- 
tion is rarely possible. The classical features of each 
are pictured on page 132. 

When doubts do arise, the therapeutic test and mi- 
croscopic examination of scrapings from the ulcerated 
spots will soon show their true nature. 

Herpes may sometimes closely simulate tuberculo- 
sis, and particularly when occurring in phthisical in- 
dividuals. The herpetic eruption in the beginning con- 
sists of numerous small vesicles that are not easily 
mistaken, but when these break down into ulcers and 
become covered by a yellowish false membrane, they 
may bear a striking similarity to miliary tubercles. 



362 PHAKYNGEAL TUBERCULOSIS. 

They appear upon all parts of the pharynx, the poste- 
rior wall, pillars, tonsils and palate, and are accom- 
panied by severe pain, odynophagia and muffling of 
the voice. Herpes runs an acute course, however, and 
this clears the diagnosis within a few days. 

Thrush likewise may be confused with an acute mil- 
iary outbreak in the pharynx, but the patches of mem- 
brane are easily detached and under the microscope 
show the oidium albicans. In both of these diseases 
the areas of mucosa between the spots are much more 
hyperemia than in tuberculosis. 

Between lupus and tuberculosis we have, in the for- 
mer condition, an afebrile course, sensitiveness rather 
than pain, complete absence of dysphagia and odyno- 
phagia, a sluggish development, and points of ulcera- 
tion, tubercle formation, and cicatrization side by side. 
Tuberculosis shows no tendency towards spontaneous 
healing, hence scar tissue is never present. 

When palatal ulceration has advanced to perfora- 
tion, a number of conditions must be taken into con- 
sideration: trauma, syphilis, malignancy, the Mai Per- 
forant Buccal, and openings of a congenital origin. 

The perforation due to syphilis is generally of large 
size, has a distinct, punched-out appearance, has no 
contiguous yellow granulations, and is usually provo- 
cative of more extensive necrosis than the opening 
due to tuberculosis, and other signs of the disease can 
practically always be uncovered. (Plate XXX., Fig. 
82). 

In tuberculosis sequestra never form and there is 
never more limn one opening; in syphilis there may be 
several, and the former condition attacks by prefer- 



PLATE XXXI. 



Fig. 83. A deep linear tuberculous ulcer of the tongue; 

the sharply ..circumscribed infiltrate, the under- 
mined edges and deep extension give an image 

more typical of syphilis than of tuberculosis. 



PLATE XXXI. 



Fig. 83. Tuberculosis of the tongue. 







Fig-. 83. 



PLATE XXXI, 



PROGNOSIS. 363 

ence the middle part of the velum, while syphilis usu- 
ally affects the osseous walls. 

The mucosa in syphilis is red and angry, in tubercu- 
losis generally anemic. 

In tuberculosis, the pharyngeal process is frequent- 
ly associated with characteristic lesions of the gums, 
lips and tongue. (Fig. 70, Plate XIX., Fig. 83, Plate 
XXXI., Fig. 84, Plate XXXII., and Fig. 85, Plate 
XXXII.) 

The Mai Perforant Buccal, according to Newcomb, 
has been noted especially in tabes, and may follow 
pyorrhea alveolaris. He says : 

u In the tabetic cases, we find sensory disturbances 
in the trigeminal area, especially close to the ulcera- 
tion. The openings are often bilaterally symmetrical, 
and occur by preference at the periphery of the bone 
near the alveolar border, in a direction parallel to the 
axis of which the ulcer is elongated. The openings 
are of considerable size, and the attempts at repair are 
indolent. ' ' 

PROGNOSIS. 

The prognosis in both the primary and secondary 
forms of the disease is usually unfavorable. Lesions of 
an incipient character may occasionally be overcome, 
but when they have once gained a firm foothold, especi- 
ally if associated with severe pulmonary or laryngeal 
phthisis, one is not justified in holding out any hope 
of arrest or even temporary betterment. 

Treatment for the purpose of local palliation and 
of producing euthanasia, is almost equally futile. Oc- 
casionally, when the infected areas are strictly circum- 
scribed or even when widelv distributed, if shallow 



364 PHARYNGEAL TUBERCULOSIS. 

and non-confluent, arrest may ensne. Such cases, how- 
ever, are of the greatest rarity. 

The lesions limited to the posterior wall offer the 
best chance of arrest. 

Grleitsmann reports one case of primary tuberculosis 
of the mouth and pharynx in which a cure was attained, 
and Theisen (Jour. Amer. Med. Assoc, Aug*. 12, 1899) 
cured one case in which both the lungs and larynx 
were involved in addition to the pharynx. 

I have seen two cases with a favorable issue : one, 
a patient with an acute miliary outbreak in the larynx 
and pharynx (Case X, page 132) recovered and was 
living eighteen months after the last symptoms dis- 
appeared; the other has made a partial recovery, but 
only two months have elapsed since the last vestige of 
ulceration disappeared and there is still considerable 
infiltration of the posterior pillars. During the pha- 
ryngeal outbreak there was recurrence in the larynx, 
and the epiglottis, previously unaffected, became in- 
volved. 

This case can naturally be classed only under the 
head of "temporary improvement." 

The remaining 37 patients all died within from two 
to fifteen weeks from the onset of the disease, and in 
all the pharyngeal process was complicated by ad- 
vanced disease of both the lungs and larynx. 

A r eis (Arch. f. Laryng., XII, 1902) reports a few 
en ses cured by trichloracetic acid. Isolated cases of a 
like nature have been reported by various observers, 
i. e., one case each by 

Boluminski (Beitr. z. Inhere, d. ob. Lnftwege, Diss. 
erlangen, 1895) ; 









PLATE XXXII. 



Fig. 84. Extensive tuberculous ulcer of the lip in a 
patient with advanced disease of the lungs and 
larynx. 

Fig. 85. Tuberculous ulcer of the tongue (Dr. T. E. 
Carmody). 



PLATE XXXII. 



Fig. 84. Tuberculosis of the lip. 

Fig. 85. Tuberculous ulcer of the tongue. 




Fig. 84. 




(aval 



Fig. 85. 



PLATE XXXI 



prognosis. 365 

Schmiegelow (Hospitals-Tidende 49, 1884) ; 
Seifert (Handbuch dew Laryn. u. Rhinologie, pg. 
730); 

Luc (Arch. d. lar., Nr. 1, 1889) ; 

TTroblewski (Wien med. Pr., 14, 1893) ; 

Phider (Deutsche med. Wochenschr. Vereinsbeil, 6, 
1896); 

Doutrelepont (Deutsche med. Wochenschr., 46, 
1892); 

Heryng (Gaz. lek. 31, 1892) ; 

Talamon (Ann. d. mat. d VOr., Nr. 5, 1894) ; 

Uckermann (Norsk. Magaz. f. Laegevidensk., 1884) ; 
and Finkler (Berl. Klin. Wochenschr., 1884.) 

Each of the following has seen two cases of healing: 

Lennox Browne (Centralbl. f. Laryngologie, IV, 

1888) ; 

Kiissner (Deutsche med. Wochenschr., 1881). 

Additional cures are reported by Michelson (Deut- 
sche med. Wochenschr., pg. 718, 1891) ; Renvers (Deut- 
sche med. Wochenschr., 14, 1891) ; Rosenberg (D. 
Krankh. d. Mundhohle, 1893), and Carmody (personal 
report). 

The proportion of cures to the total number of cases, 
however, is so small that one is scarcely justified in an- 
ticipating anything but rapid and uninterrupted prog- 
ression, with death within a comparatively few weeks. 

Isolated disease of the tonsils, either secondary or 
latent, may be completely cured if the entire organ is 
promptly and thoroughly extirpated, although the 
traumatism is sometimes accountable for the accession 
of pulmonary phthisis. 



366 LARYNGEAL TUBERCULOSIS. 

When palatal perforations occur, independent of any 
other local or general focus, they sometimes close spon- 
taneously; if they are of considerable size, they may 
be permanently repaired by operation. 

TREATMENT. 

The treatment of tuberculous pharyngitis falls na- 
turally into two divisions: curative and palliative. 

The former should embrace, primarily at the least, 
all cases in which the lesions are fairly circumscribed, 
and particularly if limited to the posterior wall or ton- 
sil, regardless of the state of the lungs and larynx. 

The reason for this is plain: the process, if 
unchecked, leads invariably to excruciating and un- 
conquerable pain, and hence every effort should be put 
forth to cause cicatrization, even when the general dis- 
ease is so far advanced as to render the prospect of 
cure or even temporary arrest absolutely hopeless. 

The same effort is justifiable in extensive pharyngeal 
disease unassociated with other lesions that would of 
themselves prove fatal. If, however, radical interven- 
tion is made in cases combining advanced pharyngeal 
and pulmonary or laryngeal tuberculosis, where the 
general vitality is low, harm only can result, for new 
and increased activity is the rule in such cases, and the 
suffering of the unfortunate patient is more apt to be 
aggravated than lessend. 

Radical or curative treatment consists in the use of 
the curette, electric or thermo-cautery, and cauterizing 
pigments, of which the most effective are formalin and 
lactic acid. All of these agents have been minutely 
considered in the chapter on treatment of laryngeal tu- 
berculosis, and since the same general principles apply 



TREATMENT. 367 

to the pharynx as to other segments of the throat, no 
separate description is required. 

Palliative Treatment : Palliative treatment is much 
less effective than in the larynx. In the latter location 
a radical removal of the affected tissues is frequently 
possible, but in the pharynx such a procedure is only 
rarely advisable. 

Likewise, the various medicaments brought into con- 
tact with the laryngeal mucosa can be retained for a 
considerable period, while in the pharynx they are 
almost immediately removed by the constant motion to 
which the parts are subjected by the passing secretions, 
the muscular contractures during deglutition, &c. 

The powders, for this reason, are largely without 
effect, and because of their drying properties are ex- 
tremely disagreeable. Neither can we make use of the 
oily preparations holding the anesthetic powders in 
solution, which, upon evaporation, leave a film of pow- 
der over the affected spots. 

In fact, we are reduced largely to the use of one class 
of remedies, the local anesthetics, cocain, alypin, &c. 

The patient should be permitted to use these ad 
libitum, in gradually increasing strengths, with occa- 
sional interchange from one to the other, in order to 
avoid in so far as possible the development of a more 
or less pronounced toleration. Orthoform and anes 
thesin, insufflated thoroughly upon the ulcerated spots, 
will give some fleeting relief and may be used in con- 
nection with other remedies. 

Curettement, with the after application of one of the 
cauterizing pigments, oftimes affords some relief. 



368 PHARYNGEAL TUBERCULOSIS. 

The local, internal and hypodermic nse of morphin, 
in quantities sufficient to produce the nearest possible 
approach to euthanasia, is always justifiable. Unfor- 
tunately, even this remedy, our last resource, usually 
fails to completely master the pain. 



INDEX 



Abercrombie 338 

Abortion, induction of, in laryn- 
geal tuberculosis 251, 252 

Abraham 330, 351 

Abscesses, perichondrial . 120, 121, 122 

— retropharyngeal 41, 360 

Accessory sinuses, tuberculosis 

of 269,274,291, 297 

Acute laryngitis, etiologic role of . . 65 
Adenoids, influence of, on infec- 
tions 32,313, 317, 318 

— opthalmo-reaction in 321 

—removal of 309, 317, 318 

Adenoid tuberculosis, etiology 

of 310, 311, 313, 316, 317 

—frequency of. . .308, 309, 322, 323 
— historical data concerning. .308, 309 

—influence of 317, 318 

—latent. 30-35, 310, 319, 320, 321, 322 

—pathology of 308, 320 

— secondary 310 

— types of 319 

Adhesions, laryngeal .... 94, 123, 124 

— pharyngeal 358 

— pleuritic, effect on voice of 83 

Adrenalin 228, 242 

After-treatment of operations .... 242 
Age, influence of, in laryngeal tu- 
berculosis 59, 60, 61 

— in nasal tuberculosis 277, 278 

■ — in nasal lupus 278 

— in pharyngeal tuberculosis 338 

Age, influence on prognosis 159 

Aguarmo 359 

Albers 18, 28 

Alcohol, influence of 64, 191 



Alexander 279 

Altitude, effects of. 181, 183 

Alveolus, perforation of 293 

Alypin 201 

Amblyphonia 81 

Amyloform 202 

Anemia, general 81, 98 

—laryngeal 78, 97, 98 

— palatal 97, 355 

— pretuberculous 97, 98 

Anesthesia, local 228 

Anesthesin 199, 214 

Angelot 127 

Ankylosis, crico-arytenoidal . . . . 

86, 120, 121, 154 

Anodynes, local 197, 200, 201 

—general 229, 368 

Anterior commissure, conditions 

at 103, 122, 124, 125 

Anterior wall, ulceration of 118 

Antiseptic sprays 200 

Antrum of Highmore, tubercu- 
losis of 269, 292, 293 

— infection through 274 

Aphonia, functional 81, 82 

— organic 82-86 

Applications, frequency of 204 

— solutions 205-215 

Applicators, laryngeal 203 

Aphthous ulcers 

(see arrosion ulcers). 

Argyrol 211 

Arid regions, influence of 183 

Aristol 202 

Ariza 23 

Arrosion ulcers. . .53, 54, 55, 76, 109 



372 



INDEX. 



Aryteno-epiglottidean disease .... 

52, 105, 118 

— prognosis of 151, 152 

Arytenoids, edema of 106, 118 

—fixation of 86, 120, 121,154 

- — frequency of involvement 52 

— infiltration of 104 

— perichondritis of 119, 120 

— prognosis of involvements of 

151, 152 

— ulceration of 118 

Aspergillus Fumigatus, inhalation 

experiments with 314 

Atrophic rhinitis, influence of on 

infections 278, 280, 281, 316 

—frequency of in phthisis 279 

Atrophy of laryngeal muscles. 78, 83 

Audry 277 

Aural pain, in dysphagia 91 

Auto-infection 56 

Auto-insufflation 201 | 

Avellis 307, 326, 360 

Avocations, influence of 62 

Babbington 21 

Babes 35 

Bacillus prodigiosus, inhalation 

experiments with 270 

Bacillus, tubercle, effect of large 

numbers 272 

— encapsulation of 74 

— as corpus alienum 68 

— inhalation of 

41. 267, 268, 313, 314, 315 

-in food 331, 336 

— in nose 268 

— in s< cr< t ions 315 

in tissues 50, 74 

penel ra.1 ion of 51 , 313 

Baillie, Matthew 14 

Barbier 35'.) 

Barry 3 12 

Barth is. :-57. 304, 329, 338 

Barthez 22 

Bartletl 3 12 

Baumgaii n 336 



Baup 34, 332, 344 

Baurowicz 254 

Beaumes 21 

Beck 218 

Beermann 275 

Beitzke 348 

Belloc 18, 22, 28 

Bender 276, 277 

Benzoin, Co. Tr., 200 

Bernheim 37 

Bezold 62 

Biftick a la Tartare 187 

Billroth 253 

Birch-Hirschfeld 37 

Bleeding, after operation 241, 242 

— from larynx 89 

— effect of, on voice 84 

— from nasal tumors 283 

— from tonsils 357 

Bloch 276, 277 

Blood vessels, alterations of 77 

— infection by 47-57 

Bocher 332 

Boluminski 364 

Bond 254 

Borsieri 17 

Bosworth 25, 145 

Bovet 99 

Bozzini 21 

Bresgen 277 

Breus 341 

Bridge 66 

Brindel. 33. 310 

Broca 33. 310 

Bronchial glands, frequency of in- 
volvement of 32, 33 

— infection from 31, 33 

— pressure by 49. 83 

Brown, Prica 243. 247 

Browne. Lennox. .247, 330, 351. 365 

Brims 25 

Broussais 14 

Buhl ' 5S 

Caboche.267, 270. 277. 285', 290, 299 
Cadier 36, 357 



INDEX. 



373 



Calmette reaction . , 321 

Carcinoma 140 

Carmody, T. E 

....101, 115, 123, 292, 293, 365 

Cartaz 263 

Cartilages, abscesses of. .120, 121, 122 

— inflammation of 

79,119, 120, 121, 122, 152 

Caseation 73 

Cases, illustrative 163-174 

Castex 229, 247 

Catarrh, laryngeal 65, 95, 133 

— nasal, influence of 273 

— nasopharyngeal 315 

— pretuberculous 95, 96 

Catarrhal laryngitis, as predispos- 
ing cause 65 

— diagnosis of 133 

Catarrhal ulcers 54, 55, 109 

Catti 127, 357 

Cazenave 261 

Cells, endothelial 71 

— epithelioid 71 

— lymphoid 71 

— giant 72, 73 

Cervical glands, infection of larynx 

from 31, 34-42 

— infection: of, from tonsils.. 31, 

34, 35, 38, 40, 330 

— enlargement of, in nasal tuber- 
culosis 301 

— enlargement of, in pharyngeal 

tuberculosis 317, 360 

Champeaux 38 

Chappell 211, 214, 215 

Chatelier 308 

Chavasse 254 

Chiari 39, 247, 275, 277 

Children, tuberculous laryngitis in 61 

- — treatment of 250 

Chinosal....- 202 

Chondritis 79; 319-324 

Chorditis granulosa 113 

Chronic laryngitis 65, 95, 133 

Cicatrices, laryngeal 94, 123 

— pharyngeal 358 

Cinnamate of soda 195 



Clarke 279, 337 

Cleft cord 112 

Climate, influence of 176-181 

Coakley 276 

Cocain 200, 228 

Codein 197 

Cohen, J. Solis 61 

Colberg 20 

Columbat 16 

Colorado, climate of 182 

Commissure, anterior, adhesions 

of 124 

— tumors at 125 

Cone 339 

Contra-indications to operation. . 

224-226, 236, 237 

Cordes 346 

Cords, vocal, congestion of 

95,96, 133 

—infiltration of 102, 103, 133 

— paralysis of 49, 78 

— tumors of 125 

— ulcerations of Ill 

Cordua 341 

Cornet. .31, 32, 39, 42, 272, 334, 350 

Cornil 33, 308, 310, 329 

Correspondence of pulmonary and 

throat lesions 47, 48, 49 

Cough, catarrhal 88 

— character of 87 

— effect of lingual glands on 88 

— laryngeal 88 

— nervous 88 

— pharyngeal 88 

— pulmonary 87 

— suppressed 274 

— treatment of 197 

Cozzolino 277 

Creosotal 197 

Creosote 197, 211 

Cricoid perichondritis 79, 121 

Crie de Canard 360 

Crossfield 337 

Cure, duration of 161 

— percentage of 146, 147, 148 

— spontaneous 160 

—statistics of 146, 151, 152, 135 



374 



INDEX. 



Curettage, indications for 

232, 234, 237, 239 

— contradictions to 234 

— methods of 226 

Curettes, single 230 

—double 231, 232 

Czermak 22 

Dansac 78, 83 

De Bono 272 

Dehio 36, 253 

De Lamallerie 58 

Delavan 269, 332, 337, 358 

Demme. . .31, 33, 263, 264, 276, 278 

Dempel 33 

De Santi 141 

Diagnosis, from catarrh 132, 133 

— from leprosy. . . 139 

— from lupus 139 

— from malignant growths 140 

— from pachydermia 134 

—from syphilis 134, 297, 298 

Diet 184-190 

Dieulafoy. ...33, 327, 330, 332,343 

Diplophonia 86 

Dmochowski 

194, 265, 292, 306, 310, 346 

Donatus 27 

Doutrelepont 365 

Drinks, preparation of 187 

Dryness of throat 187 

Dubief 308 

Duotal 197 

Dusty occupations, effect of 63 

Dysphagia, causes of. 90, 91. 92,352 

—diet in 184-190 

— frequency of 90 

— prognosis of 154 

-treatment of 200,201 

.202, 216,219, 227, 235-243, 367 

Dyspnea, causes of 92, 93, 94 

prognosis of 155 

treatment of 226, 250 

Ear, referred pain of 91 

Edema, laryngeal 106, 227 



— pharyngeal 354 

Edsall 341 

Eichorst 58 

Eisenbarth 160 

Electric light treatment 219 

Electrolysis 244 

Ellis 145 

Endogenetic infection 47-57 

Endolaryngeal operations 222-245 

Enemate, nutrient 190 

Entrance of food into larynx 90 

Epiglottis, tuberculosis of, 106, 114, 122 
— association with other lesions.. . 152 

— defects of 114 

— destruction of 114 

— dysphagia from 151 

— frequency of 52 

— infiltrative from of 106 

— location of lesions in 115, 135 

— perforations of 115 

— perichondritis of 79, 122 

— prognosis of 151, 240 

—removal for 238, 240 

— treatment of 226 

— ulcerative form of 114 

Epithelioma : 140 

Eppinger 331 

Erosions, infection through 43 

Escat 277 

Esophagus, tuberculosis of 

339, 340. 341. 342 

Ethmoidal sinus, tuberculosis of 

269, 295 

Eucalyptus 200 

Eustachian tube, involvement 

about orifices of 304, 325 

Eusthanasia, production of 368 

Excision 235-241 

Exogenetic infection 47-57 

Expectorants 198 

Expiratory insufficiency, vocal ef- 
fects of 81, 82 

Extralaryngeal operations. . . .246 259 
Extrinsic lesions, influence of. on 

pain 85 

—influence of. on voice. '. 86 

— prognosis of 154 



INDEX. 



375 



False cords (sse ventricular bands) 

Fantoni 15 

Fasona 202 

Fatty degeneration of muscles . 78, 83 
Faucial tonsils 

30-35, 327, 328, 343-347. 357 

Feeding in tuberculosis 184-190 

Ferrand 93 

Fever, in laryngeal tuberculosis. . . 89 

— in pharyngeal tuberculosis 352 

— after operations 90, 242 

Fibrous transformation 73 

Finder 247 

Finkler 365 

Finsen light 218 

Fischer.. , 33, 36, 310 

Fixation of arytenoids 

86, 120, 121, 154 

Food, choice of in laryngitis 185 

— entrance of into larynx 90 

— entrance of into naso-pharynx 

...., 316, 317 

— infection by 336 

Foods, preparation of 185-188 

Forceps, tube 230 

—Lake's 230, 231 

— Pfau's 230 

— Scheimann's 241 

Formalin 207, 208, 209, 210 

Forster 25 

Frankel, B... 152, 247, 262, 332, 337 
Frankel, E 

. .49, 51, 83, 265, 269, 292, 305, 353 

Frank 265, 294, 330 

Freudenthal 193, 278, 315 

Frey 58, 219 

Friedlander 261 

Friedmann 33, 34 

Friedreich 21, 48 

Friedrich Ill, 336 

Frisco 272 

Frobelius 61 

Frommel 58 

Frontal sinus, tuberculosis of. . 269, 294 

Galen 27 



Galvano-cautery 243 

Galvano-cautery snare 240 

Garcia 21 

Garre 37 

Gaudier 247, 265, 276 

Gaul 58 

Gerber 266, 269, 285, 287 

Gerhart ' 22 

Gerster 254 

Giant-cells 71 

Gland-ducts, infection through. ... 50 
Glands, bronchial. .31, 32, 33, 49, 83 
— cervical. .. .31, 34, 35, 38, 39, 

...40, 41, 42, 142, 301, 330, 360 

—lingual 88, 193, 194, 346 

— submaxillary 301 

Gleitsmann.36, 215, 236, 243, 292, 364 

Glover 275 

Gluck 254 

Godskesen 156 

Goris 254 

Gottstein 33, 310 

Gougunheim .78, 247, 275 

Granular cords 113 

Granulation tissue 

76, 111, 113, 281, 286 

Grazzi 247 

Green, Horace 348 

Griinwald 40, 211, 253, 265 

Guaiacol 197, 213 

Guillotine, author's epiglottic 232 

Gussenbauer 258 

Guttmann 329, 332, 358 

Habermann 307, 310 

Hahn 265, 273 

Hajek 233, 264, 305, 326 

Hamilton 279 

Hanot 342 

Harris 335 

Hardie 61 

Haslund 3? 

Hedderich 212 

Heintz 332 

Heinze 27, 51, 58, 61, 71 

Helio-therapy 216 



376 



INDEX. 



Heller 337 

Hemorrhages, after operation. 241, 242 

— from larynx 89 

— from nasal tumors 283 

— from tonsils 357 

Henning 253 

Henrici 247, 248 

Heroin 197 

Herpes 361 

Heryng 29, 161 

• . 214, 222, 228, 236, 242, 262, 265 

Heryng, curettes 230 

Herzog 275 

Hessler 318 

Hetol 195 

Hewlitt 270 

Heymann 337 

High altitudes 181, 183 

High frequency current 216 

Highmore, antrum of. 269, 274, 292, 293 

Hildebrandt 314 

Hinkel 305 

Hippocrates . ' 13 

History of laryngoscopy 21, 22 

— of laryngeal phthisis . 13-29 

— of nasopharyngeal phthisis . . 304-309 

—of nasal tuberculosis 261-267 

— of pharyngeal tuberculosis . . 327-331 

Hoarseness, functional 81 

—organic 82, 85, 86 

Hoffmann 247 

Hopmann 253 

Home 37 

Howard 292 

Humidity, effect of 182 

Hurd 311 

Hygiene of nose and throat 192 

Hygienic treatment 175-194 

Hynitsche 33 

Hyperpyrexia 353 

Ice, local use of 188 

Ichthyol 210 

Illustrative cases 163-174 

[minimization 196 

Immunity, factors governing. .47, 
. .53,270,271,314,315,333,334,335 



Incision 226 

Indications for operation 

222-226, 232, 236, 237, 

. .239, 302, 317, 318, 326, 366, 367 

Infection, auto 56 

—blood 47-57 

— inhalation43, 267, 268, 313, 323, 315 

'- — influence of rest on 183, 184 

— mixed 51, 79 

— of external incisions 238 

— in internal incisions 238 

— primary 30-46 

—secondary 30-46 

— sputal 47-57 

Infiltration, as first symptom .... 99 

— pathology of 69 

— laryngeal .'.-... .99-107 

— nasal 281 

— pharyngeal 354 

Ingals 145 

Ingersoll 292 

Ingesta, infection by 336 

Inhalations 199 

Inhalation infection 

43, 267, 268, 313, 314, 315 

— experiments. 270 

Injections, intratracheal 212 

—submucous 214 

Inoculation experiments 

271, 272, 310, 331, 348, 350 

Instruments 229, 232 

Insufflations, auto 201 

— anesthesin 201 

— aristol 202 

— iodoform 201 

— orthoform 201 

— uiorphin 202 

Inter-arytenoid space, tuberculo- 
sis of, frequency 52 

— infiltration of 101 

— tumors of 126 

— ulceration of 110 

Intratracheal injections. . 212 

Intrinsic lesions, influence on 

pain 85, 91 

— influence on voice 86 

Intubation 252 



INDEX. 



377 



oldine vasogen f 212 

Iodoform 201, 213 

Iodol 202 

Isambert 42, 32S, 336 

Ito 34 

Jackson 33 

Jaruntowski 338 

Jewish people, frequency of tuber- 
culosis in 66 

Jones, W. Noble 268, 314 

Josephsohn 37 

Jurasz 48, 59, 62 

Kafemann 244 

Kahn 308 

Kayser 359 

Keckwick 285, 276 

Keimer 247 

Kreler 101 

Kelson 38 

Kessler 358 

Kiar 273 

Kidd 59, 332 

Kijewski 254 

Killian .110, 265 

Kinsberg 302 

Kirstein, method of examination. . 110 

— tongue depressor 240 

Knight 268 

Koch 253 

Kocher 258 

Konig 39, 263 

Koplik. 350 

Korkunoff 50, 71 

Koschier 307, 325 

Kossel 274 

Krause... .29, 195*205, 214, 222, 358 

Kreig 48, 58, 233, 236 

Krishaber 142 

Kriickmann 330, 345, 351 

Kruse. . '. 58, 59, 62 

Kiier 337, 357 

Kundrat 341 

Kunze 265, 294 

Kiister 253 

Kussner 336, 358, 365 

Kuttner 156, 158, 251, 254 

Kyle, J. B 291, 337 



Lachrymal duct, extension to. 301, 302 

Lactic acid 205 

Lake 44, 58, 60, 62, 146, 183, 215 

Lake's forceps 230, 231, 240 

Landgraf 83 

Lapalle 292 

Lartigan 33, 42, 332 

Laryngeal tuberculosis : 

— diagnosis'of 130-142 

—etiology of 30-67 

—history of 13-29 

— objective symptoms of 95-129 

—pathology of 68-79 

— primary infection in 30-46 

— prognosis of 143-162 

— secondary infection in 30-46 

— subjective symptoms of 80-94 

— treatment of, climatic 176-184 

— treatment of, dietetic 184-191 

— treatment of, medicinal .... 195-221 

— treatment of, operative 222-259 

Laryngectomy 258 

Laryngitis, acute 65 

— chronic 65, 95, 96 

— hypoglottica 107, 119 

Laryngo-fissure 

251, 253, 254, 255, 256, 257 

Laryngoscope, invention of .. . .21, 22 

Larynx, anemia of 78, 97, 98 

— catarrh of 132 

— carcinoma of 140 

— hyperemia of 65, 95, 133 

— leprosy of 139 

— lupus of 139 

— methods of infection of 30-57 

— pachydermia of 134 

— syphilis of 134 

— tuberculosis of 13-259 

Latent disease of tonsils . . 30-35 

. .310, 317-322, 330, 331, 343-347 
Lateralization of laryngeal and 

pulmonary lesions 47, 48, 49 

Lathan 34 

Laveran 262 

Lemonade, cream 186 

Leprosy, diagnosis from tubercu- 
losis 139 



378 



INDEX. 



Lermoyez. . . .33, 236, 270, 309, 310 

Letulle 357 

Levy 146. 181, 250 

Lewin 24, 33, 35, 322, 332 

Liability of various parts to infec- 
tion 52 

Liaris 270, 279 

Liebermann 21 

Lieutaud 15 

Lingual glands, frequency of invol- 
vement 193, 194, 346 

— influence on cough 88 

Liquids, difficulties in swallow- 
ing 185, 187 

Liquid foods 185, 186, 187 

Liquid foods, methods of taking. . 

189, 190 

Liston 22 

Locale of lesion, prognostic signi- 
ficance of 150, 151, 152, 153 

Lloyd 258 

Lock 254 

Lori 338, 357 

Louis 16, 17 

Lozenges 197 

Lubarsch 341 

Lublinski 58, 62, 329, 332 

Luc 308, 365 

Lupus, laryngeal .39, 139 

—nasal 276, 277, 298 

— pharyngeal 362 

Luschka's tonsil, tuberculosis of. . 

317, 318, 319 

Lymphatic glands, cervical. .31, 

34, 35, 38, 40, 42, 301, 330, 360 

—bronchial 31,32,33,49,83 

—lingual 88, 193, 194, 346 

— submaxillary 301 

Lymphatic vessels, infection by 

. .47-57, 274, 316, 330, 331, 336 



Maccayden 34 

MacConkey 34 

MacKenzie.58, 62, 143, 247, 262, 353 

Magellan 48, 48, 62 

Magnetus 14 



Major 214, 215 

Mai perforant buccal 362 

Mandl 23 

Manual pressure as aid to degluti- 
tion 189 

Mascarel 229 

Marcet 28 

Massei 247. -267 

Massier " . 155 

Maxillary sinus, infection through. 274 

— tuberculosis of 269, 292, 293 

Maydl 265 

Mazzotti 341 

McBride 33 

McKinney 41 

Meningitis, tuberculous. .263. 274. 296 

Menthol 197. 231 

Mercier 284 

Meyer 22 

Michel 265 

Michelson 305, 362 

Microscopic appearance of tuber- 
culosis 68-79 

— examination of secretions 138 

— examination of tissue 138 

Miliary tubercles, of larynx 

77, 126, 127. 128. 155 

—of pharynx 306, 329, 356 

Milk, methods of taking 185. 189 

Milliard 262 

Minder 292 

Minin light 218 

Mixed infection 50, 79 

Monochorditis, diagnostic signifi- 
cance of 133 

Morgagni 15 

Moritz 37 

Morphin 229. 368 

Morton 14 

Moure 276 

Mucous membrane, changes in. ... 78 
Mucus, antitoxic properties of . . . . 270 

Mummenhoff 277 

Muscles, fatty degeneration of. . . . 78 
waxy degeneration of 78, 83 

Nargol 211 



INDEX. 



379 



Nasal obstruction, correction- of . . 

192, 193 

Nasal tuberculosis: 

— accessory sinuses, involvement 

of 269, 274, 291, 292, 

293, 294, 295, 296, 297 

—diagnosis of 297, 298, 299, 300 

—etiology of 267-278 

—frequency of 268, 269, 281 

—history of 261-267 

—lupoid form of. . .276, 277, 290, 298 

—ozena in 278, 279, 280 

— primary infection in 

.265, 273, 274, 275 

— prognosis of 301, 302 

— secondary infection in 273-277 

■ — septal perforations in 291 

— symptoms of 281-291 

— treatment of 302, 303 

—types of 266, 281 

Nasopharyngeal tuberculosis: 

—etiology of 309-318 

— frequency of 310, 311 

—history of 304-309 

— involvement of adenoid tissue 

in. .308, 309, 310, 311, 313, 

316,317,319,320, 321,322 

— primary infection in. .305, 307, 

310, 317, 320, 322, 325 

— prognosis of 325, 326 

— secondary infection in 

310, 311, 316, 323, 326 

— symptoms of 319-326 

— treatment of 325, 326 

— types of 319 

Nationality, influence of 66 

Navratil 328 

Neidert 36 

Nerves, diseases of 78, 83 

Nervous cough 88 

Neuritis 78, 83 

Newcomb 359 

Newmann 342 

Newmayer 265, 274 

Nichol 33, 42, 332 

Nose, atrophy of 

278, 279, 280, 281, 316 



— bacilli in 268 

— deformities of 192 

— filtering function of 267 

— frequency of tuberculosis of . . . . 269 

— prognosis of tuberculosis of 301, 302 
— symptoms of tuberculosis of 281-291 

— treatment of 302, 303 

— types of tuberculosis of 266, 281 

Northrup 305 

No walk 342 



Objective symptoms: 

— of laryngeal tuberculosis 95-129 

— of nasal tuberculosis 282-291 

— of nasopharyngeal tuberculosis . 

319-326 

— of pharyngeal tuberculosis. .353-361 
Occupations, influence of. . .62, 63, 64 

Odynophagia 90 

Olympitis 236, 275 

Onodi 303 

Open air treatment 183 

Operations, after-treatment of. . . . 242 
— complications from.. . .235, 236, 238 

— contra-indications to 222-226 

—external 246-259 

—indications for. .222-226, 232- 

236, 237 

339, 302, 317, 318, 326, 366, 367 

—internal 222-245 

—nasal 192, 193, 302, 303 

— nasopharyngeal 317, 318, 326 

— pharyngeal 366 

Oppikofer 292 

Opsonic treatment 197 

Ophthalmo-reaction 321 

Orth 31, 39, 54, 127, 336, 351 

Orthoform, emulsion 214 

— insufflation of 201 

— lozenges 197 

Over-treatment 204 

Ozena, frequency of, in tubercu- 
losis 278, 279, 280 

— influence of on infection 280 

Ozeki 351 



380 



INDEX. 



Pachydermia 134 

Palate, anemia of 97, 355 

— congestion of 97 

—imperfect closure of 316, 352 

— infection through 274 

— infiltration of 355 

— pain referred to 91 

— perforations of ...... . 116, 358-362 

— primary tuberculosis of 358 

— secondary infection of 359 

— ulcerations of 355, 356, 357, 358 

Pallor, local 97 

— general 81, 98 

Pancoast 217 

Panse 265, 294, 295 

Panzer 125 

"Papillaere" infiltration 102 

Paralysis of cords, primary 49 

— secondary 78 

Para-mono-chlor-phenol 211 

Paresthesia 84 

Park 270 

Pathology 68-79 

Parturition (see pregnancy) 

Penrose 342 

Pepper 341 

Perforation of epiglottis 115 

—of palate 358-362 

— of septum 391 

Perichondritis of arytenoids ..112, 119 

—of cricoid 79, 121 

- — of epiglottis 122 

—of septum 284, 286, 290 

—of thyroid 122, 259 

Perrin 59 

Petit 15 

Pfau's forceps 230, 240 

Pharyngeal immunity. . .333, 334, 335 
Pharyngeal tonsils, etiologic role 

of 313, 317, 318 

— tuberculosis of 

307, 319, 320, 321, 322, 323 

Pharyngeal tuberculosis: 

— channels of infection in. 331 

— diagnosis of 361, 362, 363 

— etiology of 331-351 

— esophageal involvement . . . .339-342 



—frequency of 332, 333, 346 

— glandular enlargement in 360 

— history of 327-331 

— involvement of palate in 

355, 356, 357, 362 

— involvement of tonsils in. . .343-351 
— involvement of uvula in... .337, 357 
— latent disease of tonsils 343, 344, 347 

— objective symptoms of 353-361 

— primary infection in 

332, 336, 337, 351 

—prognosis of 363, 364, 365 

— secondary infection in 

331, 332, 337, 346, 347 

— subjective symptoms of. 351, 352, 353 

— treatment of 366, 367, 368 

Phillip, W. C 144 

Photo-therapy 216 

Phthisis, influence of on prognosis. 149 

— on treatment 198 

— proportion of cases with laryn- 
gitis 59 

— with nasal tuberculosis 269 

— with naso-pharyngeal tubercu- 
losis 310 

— with pharyngeal tuberculosis. . . 333 

— with tonsillar tuberculosis 

... .308, 309, 322, 323, 344, 345 
Physical characteristics, etiologic 

role of 66 

Piaget 271 

Piffl 33, 310 

Pigments 202-212 

Pilliet 33, 308, 310 

Pizzini 32 

Plicque 264 

Pluder 33, 287, 310, 336, 365 

Pogrebinski 31 

Poland 342 

Pontoppidan 277 

Portal 16 

Pottenger 195 

Pravaz 16 

Predisposing causes 58-67 

Pregnancy, influence of 

67. 155,250, 252 

— management of 250, 251, 252 



INDEX. 



381 



Pretuberculous anemia 96, 97, 98 

— hyperemia 95, 96 

— paralysis 49 

Primary tuberculosis, of larynx . . 30-46 
— of naso-pharynx . . . .305, 307, 

310, 317, 320, 322, 325 

—of nose 265, 273, 274, 275 

— of pharynx 332, 336, 337, 351 

Prognosis of laryngeal tuberculo- 
sis 143-162 

— of nasal tuberculosis 301, 302 

— of nasopharyngeal tuberculosis. . 

325, 326 

— of pharyngeal tuberculosis 

363, 364, 365 

Prolapse of ventricle 139 

Protargol 211 

Ptyalin, deficiency of 332 

Pyoktanin 211 



Radio-therapy 216 

Radium 218 

Ranvier 239 

Raudnitz 276, 277 

Rectal feeding, after operation . . . 242 

— to prolong life 190 

Recurrence 74, 153, 161 

Recurrent nerve, pressure on. .82, 83 

Referred pain, to ear 91 

— to palate 91 

Regions of larynx involved, fre- 
quency 52 

— influence on prognosis 150-153 

Regurgitation of food. . . .92, 316, 352 

Reigenier 360 

Relapse (see recurrence). 

Renshaw 272 

Renvers 365 

Resorcin 202, 210 

Rest of voice .184, 191 

Rest treatment 184 

Rethi 34, 236, 265, 274, 344, 357 

Retrograde infection 40, 347 

Retropharyngeal abscess 41, 360 

Rey 337 

RheindorfT 60 



Rheiner TO 

Richards 212 

Riedel 262 

Riehl 39, 262 

Rilliet 22 

Rindfleisch 23, 25 

Robertson '. 345 

Robinson 27, 247 

Roentgen rays 216 

Rokitansky 19 

Rosenberg.... 62, 211, 333, 337, 365 

Rosenheim 123 

Rosenmullers's fossa, lesions of304, 325 

Roth 22, 337 

Ruge 33, 39, 344, 351 

Sachse. 16, 276 

Sajous 143 

Salivary secretions, alterations of 

in phthisis 335 

Sanatorium treatment 184 

Santvoord 60, 338 

Sauvee 16 

Scarification 226 

Scar tissue 94, 123, 358 

Schaffer 48, 58, 234, 269, 275 

Schech 39, 48, 61, 76, 127, 144, 

. . 182, 211, 233, 239, 273, 286, 334 

Schech cautery handle 232 

Scheinmann 211 

Schenke 265, 294 

Schlenker 330, 345 

Schleicher 336 

Schlesinger 346, 347 

Schmalfuss 269 

Schmidt. .. .28, 36, 59, 62, 127, 

. . . 146, 222, 226, 242, 246, 247, 254 

Schmiegelow 255, 265 

Schmitthuisen 273 

Schnitzler. 126, 253, 306, 326 

Schonborn 253 

Schotz 338 

Schreiber 33 

Schrotter 48, 59 

Secondary infections of larynx . . 27-46 

— of nasopharynx 310, 311, 316, 323, 326 



382 



INDEX. 



—of nose 273-277 

— of palate 358 

—of pharynx. . .331, 332, 337, 346, 347 

Secretions, characteristics of 89 

— laryngeal, effect on cough 89 

— pulmonary, effect on cough. ... 89 

Sedentary occupations 63 

Seifert.212, 247, 308, 319, 324, 337, 365 

Sendziak 211 

Senn 21 

Septum nasi, erosions of 272 

— perforations of 291 

— tuberculosis of 288 

Sera 195, 196, 197 

Serafini 322 

Serowski 248 

Sex, influence of 62, 277, 339 

Sheedy 38 

Shurley 32, 270 

Sigaud 16 

Simanowski 211 

Sinuses, infection of nose through. 274 
—tuberculosis of. . .269, 274, 291-297 

Sokolowski 157, 236, 251, 254, 346 

Solar-therapy. 220 

Solly 145, 215, 239 

Sommerbrodt 26 

Sorgo 220 

Spengler 32, 212 

Sphenoidal sinus, tuberculosis of . . 

269, 295 

Spontaneous healing 160 

Sprays 200 

Sputum, infection through 47-57 

Staphylococci 51, 79 

Statistics, of age 

59, 60, 61, 277, 278, 338 

— of cure 145-153 

— of esophageal cases 339-342 

— of infiltrative cases 101 , 153 

— of nasal cases 26S, 269, 281 

— of nasopharyngeal cases. . . .310-311 

— of occupations 62, 63 

—of palatal perforations 35S 362 

of pharyngeal cases. . .332, 333. 346 
of proportion of consumptives 

attacked 59, 269.310, 311,332, 346 



— of regions affected 52 

—of sex 62, 277, 339 

— of tonsillar cases. .33, 34, 308, 

309, 322, 323, 344, 345, 346 

— of ulcerative cases 153 

Stein, 254 

Stenosis, treatment of 246, 258 

Steward 269,273,275,278 

Sticker 277 

Stomach tube, feeding by 190 

Stork 215, 264, 278 

Strassmann 35, 329, 345 

Strauss 268, 314 

Streptococci 51, 79 

Subglottic region, tuberculosis of 

52, 107, 119, 241 

Subjective symptoms of laryngeal 

tuberculosis 95-129 

— of nasal tuberculosis 281-297 

— of nasopharyngeal tuberculosis, 

323-327 

—of pharyngeal tuberculosis. .353-361 

Submucous injections 214 

Suchannek 305 

Sunlight treatment 219 

Suppressed coughing 274 

Surgical treatment, endolaryngeal 

222-245 

— extralaryngeal 246-259 

— of nasopharynx 326 

—of nose 302, 303 

— of pharynx 366, 367 

Sylvius 14 

Symonds 254 

Syphilis, diagnosis of . . . . 134, 297, 361 
—influence on tuberculous infec- 
tions 15S. 340 

— voice of 86, 137 

Syringes, submucous 214 

— tracheal 212 

Systemic poisoning, local symp- 
toms duo to 81 



Talamon 365 

Taptas 254 

Tarchetti 33 



INDEX. 



383 



Tear ducts, tuberculosis of 301 

Temperament,[influence of . . . 143, 175 
Temperature, afterjoperations . 86, 242 
— from laryngeal tuberculosis. ... 89 

— from pharyngeal lesions 352 

— from tuberculin 138 

Theissen 34, 279, 364 

Thiocol 202 

Thirst, management of 187 

Thompson, St. Clair 270 

Thornwaldt 262 

Thost 67, 148 

Thrush, diagnosis of 362 

Thyroid, perichondritis of. 79, 122, 259 

Thyrotomy 253-267 

Tietze 247 

Tissier 126 

Tobacco, use of 64, 191 

Tobold 23, 25 

Tonsils, pharyngeal, latent disease 

of 30-35, 308, 309, 

310, 317, 320, 321, 322 
— faucial, latent disease of. .30-35, 

327, 328, 343, 344, 346 

Touton 307, 326 

Tracheotomy 246-252 

Traumatol 202 

Trautmann 126, 307 

Treatment, dietetic 184-191 

— hygienic 175-194 

—general 195, 196, 197 

—medicinal 195-221 

— of nasal tuberculosis 302-303 

— of nasopharyngeal tuberculosis 

325, 326 

— of pharyngeal tuberculosis. . 366, 

367, 368 

— open air 180 

— post operative 242 

—surgical 222-259 

Trifilletti 37 

Trousseau 18, 22, 28 

Tubercle, structure of 70 

Tuberculin, in diagnosis 138 

— in treatment 195, 361 

Tuberculomata, faucial 603 

— laryngeal 76, 124 



—nasal 281, 282 

—nasopharyngeal 306, 325, 326 

— pathology of 76 

Tumors (see tuberculomata) 
Turbinal bodies, atrophy of. . 278, 

279, 280, 281, 316 

—tuberculosis of 282, 286 

Turck 22, 23 

Turner 33 



Uckermann 337, 358, 365 

Ulcers, characteristics of 

74, 75, 108, 109 

— non-tuberculous 53 

—of larynx 107-119 

— of nose 285 

— of nasopharynx 323 

— of pharynx 353, 354, 355, 356 

— perforating, of palate 358 

Uvula, tuberculosis of, primary. . 337 

— secondary 357 

— symptoms of 357 



Vaccines, bacterial 197 

Vacher 211 

Vagus, transference of pain through 9 1 

Valsalve 15 

Vapors, inhalation of 199 

" Vegetierende " infiltrates 102 

Veis 364 

Ventricular bands, frequency of in- 
volvement 52 

— hemorrhage from 241 

— infiltration of 106 

— miliary tubercles of 127, 128 

— prognosis of lesions of 152 

— prolapse of 139 

— tumors of 125 

— ulceration of 116 

Virchow 24 

Vocal cords, congestion of 96, 102 

— frequency of involvement 52 

—infiltration of 102, 103, 104 

— paralysis of 49, 78 



384 



INDEX. 



— prognosis of lesions of 152 

— tumors of 125 

— ulcers of Ill 

Vohsen 265, 294 

Voice, causes of alterations in. . .81-87 

— characteristics of 85 

— fatigue, as first symptom 82 

— loss of, functional 82 

— loss of, organic 85 

— prognosis, in regard to 154 

—rest of 184, 191 

Volcker 342 

Volkmann 263 

Volland 31 

Vomiting as cause af postnasal in- 
fection. 316 

Von Ruck , 195 

Von Schreiber 345 

Wagner 25, 359 

Waldenberg 23, 26 

Walsham,..34, 48, 332, 334, 314, 

.' 347, 350 

Warden 22 

Watery-extract, Von Ruck's 195 

Web formation 123, 142 

Weichselbaum 262, 269, 291 

Weigert 329 



Wendt 304, 328 

Wertheim 292 

Wex 34 

Wilder 159 

Willan 231 

Williams 214 

Willigk 58, 261, 269, 332 

Willis 337 

Wolfenden, position 189 

Wood 345, 346, 349 

Woodhead 65 

Wright, J. .17,19,33,51,144,310, 332 

Wroblewski 337, 365 

Wunderlich. : 21 

Wurtz 270 

Xanthosis 272 

X-ray 216 

Zanconi 33 

Zander 265 

Zawerthal 304 

Zemann 341 

Zenker 341 

Ziemssen 26, 37 

Zinc chloride 215 

Zinn 212 



